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Medical Forum / Diseases and Disorders / Prostate Cancer / December 2006Is Profit Dictating Prostate Cancer Treatments?
The New York Times has posted the following questions in an article. It seems that some prostate cancer treatments are much, much more profitable than others, and this can/is (who knows) affecting recommendations. ----- The nearly 240,000 men in the United States who will learn they have prostate cancer this year have one more thing to worry about: Are their doctors making treatment decisions on the basis of money as much as medicine? Among several widely used treatments for prostate cancer, one stands out for its profit potential. The approach, a radiation therapy known as I.M.R.T., can mean reimbursement of $47,000 or more a patient. That is many times the fees that urologists make on other accepted treatments for the disease, which include surgery and radioactive seed implants. And it may help explain why urologists have started buying multimillion-dollar I.M.R.T. equipment and software, and why many more are investigating it as a way to increase their incomes. ..... Critics see a potential conflict of interest on the part of urologists, the specialists who typically help prostate patients choose a course of treatment. The critics say that urologists who can profit from the new form of therapy may be less likely to recommend other proven approaches, which for some older men can involve forgoing treatment altogether ---- "It's all money-driven, and it's a shame medicine has come down to this," said Dr. Brian Moran, a radiation oncologist in Chicago, who specializes in radioactive-seed implants, in which tiny radioactive pellets are placed into the prostate. His clinic is paid $15,000 or less for the procedure, with the urologist on the case getting about $900. ----- Anyway, it is clear you can make a lot of money in medicine. "Join the Urorad team and let us show your group how Urorad clients double their practice's revenue," the company says in a marketing pitch to doctors on its Web site. George, I'm glad that the Times put it on their front page. However, I'd like to point out another treatment issue. After reviewing survival statistics for my age/Gleason/stage/etc, I agreed with my urologist that a RP was called for. Just prior to the procedure, I was persuaded by a friend to get a second opinion from a noted oncologist. When I told my urologist, he said: "If he says don't go for an RP, get a third opinion - and make sure it's from a urologist." The trip to the oncologist was a disaster, since he did not deal with insurance companies (his fee for an initial consultation was also ten times as much as my urologist charged). After getting this news, the two women at the desk said that I should still get a second opinion from an oncologist - "those urologists are too eager to cut". It is quite distressing to suddenly find that the experts can't find common ground. So, patients already suffer from treatment bias, even when there is no financial incentive. -Patrick > The trip to the oncologist was a disaster, since he did not deal with > insurance companies (his fee for an initial consultation was also ten > times as much as my urologist charged). Rule #1 in picking providers: inquire about insurance. The handful who don't accept it cater to the very wealthy, which is their privilege. We ordinary folks still have a few hundred thousand fine providers to choose from. I.P. > > The trip to the oncologist was a disaster, since he did not deal with > > insurance companies (his fee for an initial consultation was also ten [quoted text clipped - 6 lines] > > I.P. The article stated that profit dictated the treatment recommended, or at least it might very well. However, obviously any physician recommends the treatments he/she does over those he/she does NOT do. >>> The trip to the oncologist was a disaster, since he did not deal with >>> insurance companies (his fee for an initial consultation was also ten [quoted text clipped - 9 lines] > least it might very well. However, obviously any physician recommends the > treatments he/she does over those he/she does NOT do. It certainly seems that such would be the case. But my experience suggests that such is not always true As an example, my urologist told me that I could choose either radiation or surgery. As best I could tell at the time from independent sources, that was in fact correct. I've also heard of several cases where an oncologist recommended surgery or a surgeon recommended radiation or seeing an oncologist. One tends to assume that self interest determines everything in the world, but in fact altruism still seems to be alive. > ... As an example, my urologist told me that I could choose either radiation or surgery.... > ...I've also heard of several cases where an oncologist recommended surgery > or a surgeon recommended radiation or seeing an oncologist.... My urologist gave me a choice too. When I asked him what he would have done if I opted for radiation (clearly a bad choice for me, if the survival percentages were to be believed), he said that he would have argued. When I asked him why he didn't just say: "I recommend RP"?, he said that it was important to empower the patient! I suppose that, considering the risks with any PCa therapy, it makes sense to put the onus on the patient - less recrimination down the road. But back to treatment bias. Let's say that 95% of urologists would have recommended RP, while 90% of oncologists would have too. In other words, for my situation, the two sides may have more-or-less agreed. My sense though, is that a large number of men fall into a category where treatment bias is rampant. My basis for this is that my urologist clearly felt it was not in my interests to fall into the hands of an oncologist, whilst an assistant at the oncologist's office was equally concerned that I might undergo an unnecessary RP. This bias can be distressing to the average patient, although most are probably unaware of it. There was a recent study that showed that many men choose a therapy using the thinest of information. Such as when the next door neighbor tells you that his uncle Joe had the seeds last month, "and he's doing fine"! Also, a surprising percentage of men are convinced that they made the correct decision, regardless of whether the treatment was successful. -Patrick > > ... As an example, my urologist told me that I could choose either radiation or surgery.... > > ...I've also heard of several cases where an oncologist recommended surgery [quoted text clipped - 28 lines] > > -Patrick Actually until the PIVOT studies are in, the raw information is kind of sketchy too. >> > ... As an example, my urologist told me that I could choose either > radiation or surgery.... [quoted text clipped - 33 lines] > Actually until the PIVOT studies are in, the raw information is kind of > sketchy too. First, no one study will ever be definitive enough to state what you're hoping it will. Second, there have already been european versions of the pivot study. They've shown prosate cancer results in fewer deaths when surgical inteventation is given. Third, there are a host of other studies showing that postate cancer survival improves with surgery. There is actually a LOT of good data to show that. But hey, thanks for playing. >>> > ... As an example, my urologist told me that I could choose either >> radiation or surgery.... >>> > ...I've also heard of several cases where an oncologist recommended >> surgery >>> > or a surgeon recommended radiation or seeing an oncologist.... >>> My urologist gave me a choice too. When I asked him what he would have >>> done if I opted for radiation (clearly a bad choice for me, if the [quoted text clipped - 3 lines] >>> considering the risks with any PCa therapy, it makes sense to put the >>> onus on the patient - less recrimination down the road. I believe it is ESSENTIAL that the patient make the decision, and that the physician has the responsibility of providing adequate information about the alternatives for the patient to make an intelligent decision, considering all aspects of cost, lost time, restrictions on living conditions, etc., as well as the distribution of outcomes. Also, if there is any moderate possibility of differences in patients, information on what that difference is should be clearly pointed out, even if it is tentative. The practical significance of an alternative does not depend on the samples size; the "statistical significance" (what the practitioners of the medical religion swear by) very definitely does.  SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 > >>> > ... As an example, my urologist told me that I could choose either > >> radiation or surgery.... [quoted text clipped - 23 lines] > practitioners of the medical religion swear by) very > definitely does. Herman, statistical significance would show whether or not the new techniques are superior to the old. > statistical significance would show whether or not the new > techniques are superior to the old. Gotta define "superior" first. One man's top criterion is often the next man's tenth, or lower. I.P. ..................... >> I believe it is ESSENTIAL that the patient make the >> decision, and that the physician has the responsibility of [quoted text clipped - 9 lines] >> practitioners of the medical religion swear by) very >> definitely does. > Herman, statistical significance would show whether or not the new >techniques are superior to the old. Not as much as you think, and it would be no indication of how much superior in any case. Something is statistically significant if the result of the test is less likely by chance if there is ABSOLUTELY NO effect than the preassigned significance level. It is this and nothing else. When it is extended to the p-value, that gives the level at which it is significant, but still nothing else. To give you a hypothetical example, suppose that no treatment of a condition gives a 50% recovery rate, and that the old treatment, used on one million cases, gives a 51% recovery rate. This is extremely significant. Now a new treatment has been proposed, and of the three given this treatment, all have recovered. This is not statistically significant. Which treatment would YOU take? SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 > suppose that no > treatment of a condition gives a 50% recovery rate, [quoted text clipped - 4 lines] > This is not statistically significant. Which treatment > would YOU take? No treatment. The paltry extra 1% in recovery rate isn't worth the treatment's SEs, and three oxymorons (i.e., anecdotal "evidence") don't mean squat . . . yet. I'd lose virtually nothing by waiting for the outcomes of the next 100 or 1,000 cases receiving the new treatment. I.P. <> suppose that no <> treatment of a condition gives a 50% recovery rate, <> and that the old treatment, used on one million <> cases, gives a 51% recovery rate. This is extremely <> significant. Now a new treatment has been proposed, <> and of the three given this treatment, all have recovered. <> This is not statistically significant. Which treatment <> would YOU take? >No treatment. The paltry extra 1% in recovery rate isn't worth the >treatment's SEs, and three oxymorons (i.e., anecdotal "evidence") don't >mean squat . . . yet. I'd lose virtually nothing by waiting for the >outcomes of the next 100 or 1,000 cases receiving the new treatment. You have to take the treatment now or never; you have the condition. If you think the new treatment has a 10% chance of success, or even less, you should take it, unless it is costly. SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 > <> suppose that no > <> treatment of a condition gives a 50% recovery rate, [quoted text clipped - 14 lines] > If you think the new treatment has a 10% chance of success, > or even less, you should take it, unless it is costly. Still depends on the SEs, as many people have shown here and in studies. There's a lot more to living than just breathing. I.P. >> <> suppose that no >> <> treatment of a condition gives a 50% recovery rate, [quoted text clipped - 4 lines] >> <> This is not statistically significant. Which treatment >> <> would YOU take? >>> No treatment. The paltry extra 1% in recovery rate isn't worth the >>> treatment's SEs, and three oxymorons (i.e., anecdotal "evidence") don't >>> mean squat . . . yet. I'd lose virtually nothing by waiting for the >>> outcomes of the next 100 or 1,000 cases receiving the new treatment. >> You have to take the treatment now or never; you have the condition. >> If you think the new treatment has a 10% chance of success, >> or even less, you should take it, unless it is costly. >Still depends on the SEs, as many people have shown here and in studies. >There's a lot more to living than just breathing. Suppose I add that the condition is quickly fatal if one does not recover, and those who do recover show little damage from the treatment? SignatureThis address is for information only. I do not claim that these views are those of the Statistics Department or of Purdue University. Herman Rubin, Department of Statistics, Purdue University hrubin@stat.purdue.edu Phone: (765)494-6054 FAX: (765)494-0558 >>> <> suppose that no >>> <> treatment of a condition gives a 50% recovery rate, [quoted text clipped - 21 lines] > does not recover, and those who do recover show little > damage from the treatment? Now you're playing hypotheticals. I'm talking about prostate cancer. I.P. >>>> ... As an example, my urologist told me that I could choose either >> radiation or surgery.... [quoted text clipped - 39 lines] > showing that postate cancer survival improves with surgery. There is > actually a LOT of good data to show that. But hey, thanks for playing. First, let me say that your major point is well taken. No single study is going to settle the matter. In addition, there are fundamental problems doing any prospective randomized study for a diesease like prostate cancer with a long time horizon. things just change too much so it is very hard to maintain constant parameters for a study. In addition, the protocal chosen for the study may very well turn out to be irrelevant given changes in treatment by the end of the study. A good example is that any study of PSA screening based on simply using a cut-off point of 4.0 ng/ml to trigger a biopsy is now hopelessly out of date because of new information about more sophisticated ways to use PSA testing, e.g., PSA velocity. Having said that, let me add that one shouldn't be too ready to draw conclusions for prostate cancer in the US from the Swedish studies of Holmberg, et. al. which you referred to. In Sweden, men are not generally screend for prostate cancer. The men in that study were mostly diagnosed because they approached urologists for other reasons and were checked for prostate cancer. Men in the US, where PSA testing is more common, but not universal, are likely to be diagnosed at least 5 years earlier. This has some possible consequences. First, they are less likely to develop recurrence, or, if untreated, clinical symptoms, particularly within 10 years, so any difference between surgery and WW could take much longer to show up. Second, it is possible that more men with cancers that would otherwise never have bothered them might be treated. For a typical low risk T1c, Gleason 6, cancer with PSA less than 10, experts estimate taht a significant portion are in this category. And, today, some urologists, including leaders such as those at Hopkins or Sloan Kettering, do treat some low risk cases with "expectant management". >>>>> ... As an example, my urologist told me that I could choose either >>> radiation or surgery.... [quoted text clipped - 68 lines] > including leaders such as those at Hopkins or Sloan Kettering, do treat > some low risk cases with "expectant management". And that's a treatment option I agree with depending on a person's age and overall health. Certainly in the end, the patient needs to decide. Even when presented in a positive light, most patients opt for treatment as the thought of having a cancer in their body with treatments available is usually something that swings patients to want definitive treatment. RCT's will probably never be done as it is simply considered unethical to do so nowadays. We do need to be careful to extrapolate from the Swedish study - but that's also the best study we have to date. There have also been pretty well done but retrospective studies from the States showing a pretty clear survival advantage for surgery. > >>>> ... As an example, my urologist told me that I could choose either > >> radiation or surgery.... [quoted text clipped - 42 lines] > First, let me say that your major point is well taken. No single study > is going to settle the matter. Ok, that gives you the right to disown anything you feel like, just as your long history of posting proves once again. >>>>>> ... As an example, my urologist told me that I could choose either >>>> radiation or surgery.... [quoted text clipped - 48 lines] > Ok, that gives you the right to disown anything you feel like, just as > your long history of posting proves once again. Well, there is only one relevant study with results now available. It is Holmberg, et. al., which shows that radical prostatectomy is superior to watchful waiting. Can I take it that you now reverse your position in the matter and now accept that as an undisputed fact. Or perhaps this is a case of the pot calling the kettle black? To clarify things, I think no single study should be used to decide these matters. Each study will have strengths and weaknesses, and has to be weighed with that in mind. One has to look at the sum total of avaiable information. In many cases, that will mean the situation is still not clear. I happen to believe that, despite the strong evidence from the Holmberg study, it is still not clear how effective RP is in treating prostate cancer in the US context, particularly for lower risk cases. I think the evidence is pretty clear that for Gleason 7 cases in men with at least 10 years life expectancy, aggressive treatment to cure the cancer is merited. I also think that for most men with life expectancy less than 10 years, whatever the Gleason, expectant management makes more sense. The area where we need improvement is typical Gleason 6, T1c, PSA less than 10 cases. Just what to do in such cases is unlikely to be settled, as far as I can see by any currently ongoing study. Most likely, in the next several years better diagnostic procedures for separating those cases likely to advance from those that won't will become available. Then all the current controversies about the effectiveness of screening or treatment will become moot. >> >>>> ... As an example, my urologist told me that I could choose either >> >> radiation or surgery.... [quoted text clipped - 55 lines] > Ok, that gives you the right to disown anything you feel like, just as > your long history of posting proves once again. It's really just medical fact. That's why we often see conflicting studies, or even paradigms that change because of newer/better done studies disproving previous held beliefs. Putting an entire disease management in the hands of a single study without corroborating evidence would be paramount to a combination of malpractice and simple stupidity. > obviously any physician recommends the > treatments he/she does over those he/she does NOT do. The rad onc I consulted for my prostate cancer recommended surgery once I told her I'd *M*U*C*H* rather risk bladder incontinence than fecal incontinence. I.P. >> obviously any physician recommends the >> treatments he/she does over those he/she does NOT do. > > The rad onc I consulted for my prostate cancer recommended surgery once > I told her I'd *M*U*C*H* rather risk bladder incontinence than fecal > incontinence. My urologist gave me the choice of surgery or radiation. The fact that rectal problems were a possibility from radiation was one of the reasons I chose surgery. > I.P. > >> obviously any physician recommends the > >> treatments he/she does over those he/she does NOT do. [quoted text clipped - 8 lines] > > > I.P. So you got a 29% of dribble for the rest of your life. >>>> obviously any physician recommends the >>>> treatments he/she does over those he/she does NOT do. [quoted text clipped - 8 lines] > > So you got a 29% of dribble for the rest of your life. I don't dribble. I do have a certain amount of urge incontinence, meaning that if I wait too long before getting to a bathroom, I might have a problem, I did have some minor stress incontinence for several months after surgery, but that has gone away. But many men of my age have such problems or worse, whether or not they have been treated for prostate cancer. I did, and overall I'm actually better off now than I was before my surgery. But you are right in that figures for minor stress incontinence after RP appear to be in the range 20-30 percent. This is usually a minor annoyance, and hardly a life altering problem. But, as I noted, men with benign prostatatic hypertrophy (BPH) have similar problems or worse, and most men past a certain age will suffer from that. Many older women have to wear pads. If a man already has serious BPH and has an RP, the likelihood of serious incontinence is higher. All this is known and any responsible urologist will advise such men of potential problems. >> >> obviously any physician recommends the >> >> treatments he/she does over those he/she does NOT do. [quoted text clipped - 10 lines] > > So you got a 29% of dribble for the rest of your life. No, far less than that. Urologists do not give radiation therapy; radiation oncologists do. I suppose there may be a few out there who are ambitious enough and smart enough to be able to do that, but certainly many at all. One would think the big academic places would be most susceptible to this sort of thing, but with the emergence of the robotic prostatectomy, urologists are advocating surgery as much or possibly more than in previous years. IMRT is a much improved form of radiation therapy with lower complications and a theoretical but as yet unproven ability to get higher cure rates. But really it's the fewer complications that are the key. Let me put it this way - if I had prostate cancer and opted for radiation, IMRT would be the only acceptable method for me given it's improved side effect profile over older forms of radiation. > The New York Times has posted the following questions in an article. It > seems that some prostate cancer treatments are much, much more profitable [quoted text clipped - 46 lines] > its > Web site. Just something to factor in to the equation...ron Int J Radiat Oncol Biol Phys. 2003 May 1;56(1):83-8 Radiation-induced second cancers: the impact of 3D-CRT and IMRT. Hall EJ, Wuu CS. Center for Radiological Research, Columbia University, College of Physicians and Surgeons, New York, NY 10032, USA. ejh1@columbia.edu Information concerning radiation-induced malignancies comes from the A-bomb survivors and from medically exposed individuals, including second cancers in radiation therapy patients. The A-bomb survivors show an excess incidence of carcinomas in tissues such as the gastrointestinal tract, breast, thyroid, and bladder, which is linear with dose up to about 2.5 Sv. There is great uncertainty concerning the dose-response relationship for radiation-induced carcinogenesis at higher doses. Some animal and human data suggest a decrease at higher doses, usually attributed to cell killing; other data suggest a plateau in dose. Radiotherapy patients also show an excess incidence of carcinomas, often in sites remote from the treatment fields; in addition there is an excess incidence of sarcomas in the heavily irradiated in-field tissues. The transition from conventional radiotherapy to three-dimensional conformal radiation therapy (3D-CRT) involves a reduction in the volume of normal tissues receiving a high dose, with an increase in dose to the target volume that includes the tumor and a limited amount of normal tissue. One might expect a decrease in the number of sarcomas induced and also (less certain) a small decrease in the number of carcinomas. All around, a good thing. By contrast, the move from 3D-CRT to intensity-modulated radiation therapy (IMRT) involves more fields, and the dose-volume histograms show that, as a consequence, a larger volume of normal tissue is exposed to lower doses. In addition, the number of monitor units is increased by a factor of 2 to 3, increasing the total body exposure, due to leakage radiation. Both factors will tend to increase the risk of second cancers. Altogether, IMRT is likely to almost double the incidence of second malignancies compared with conventional radiotherapy from about 1% to 1.75% for patients surviving 10 years. The numbers may be larger for longer survival (or for younger patients), but the ratio should remain the same. > Just something to factor in to the equation...ron ron, this aspect of the issue was also discussed in the times article. > Int J Radiat Oncol Biol Phys. 2003 May 1;56(1):83-8 > [quoted text clipped - 35 lines] > The numbers may be larger for longer survival (or for younger > patients), but the ratio should remain the same. > Urologists do not give radiation therapy; radiation oncologists do. I > suppose there may be a few out there who are ambitious enough and smart [quoted text clipped - 8 lines] > only acceptable method for me given it's improved side effect profile over > older forms of radiation. Based on current information, you are probably correct, but brachytherapy probably has fewer side effects than IMRT. > > The New York Times has posted the following questions in an article. It > > seems that some prostate cancer treatments are much, much more profitable [quoted text clipped - 46 lines] > > its > > Web site. >> Urologists do not give radiation therapy; radiation oncologists do. I >> suppose there may be a few out there who are ambitious enough and smart [quoted text clipped - 12 lines] > Based on current information, you are probably correct, but > brachytherapy probably has fewer side effects than IMRT. Without further elaboration, I think this statement is almost certainly false. The trouble is that there are many different forms of brachytherapy and side effects vary depending on the details of the case. Generally all forms of treating prostate cancer have similar side effects, but the frequency of a given side effect may vary from one to another depending on the patient, the practitioner, and the details of the diagnosis. Any man contemplating treatment should not rely on generalities about the likelihood of side effects. He should try to ascertain the likelihood of different side effects for men with cases like his if he is treated by a specific practitioner. But if you have some specific study in mind, I would be interested in looking at it. >>> The New York Times has posted the following questions in an article. It >>> seems that some prostate cancer treatments are much, much more [quoted text clipped - 51 lines] >>> its >>> Web site. > >> Urologists do not give radiation therapy; radiation oncologists do. I > >> suppose there may be a few out there who are ambitious enough and smart [quoted text clipped - 23 lines] > ascertain the likelihood of different side effects for men with cases > like his if he is treated by a specific practitioner. Which of course is impossible. >>>> Urologists do not give radiation therapy; radiation oncologists do. I >>>> suppose there may be a few out there who are ambitious enough and smart [quoted text clipped - 30 lines] > > Which of course is impossible. Well, it wasn't impossible in my case. My urologist told me right off the likelihoods of incontinence and impotence if he treated me with surgery. I'm sure they were rough estimates, but they were close enough to guide my decision. he has said that either eurgery or radiation wa a reasonable choice for me. Had I been five years older, radiation would clearly have had the edge with respect to impotence. Since the decision between the two methods was close in my mind, I probably would have chosen radiation had I been five years older. Of course, none of this is certain, so it may turn out with further research that my reasoning was invalid. but when choosing a course of action, each of us must use the best available evidence, and that is what I did. >> >> Urologists do not give radiation therapy; radiation oncologists do. I >> >> suppose there may be a few out there who are ambitious enough and [quoted text clipped - 33 lines] >> > Which of course is impossible. Not at all. >> Urologists do not give radiation therapy; radiation oncologists do. I >> suppose there may be a few out there who are ambitious enough and smart [quoted text clipped - 15 lines] > Based on current information, you are probably correct, but > brachytherapy probably has fewer side effects than IMRT. It has different side effects. Doesn't appear to have fewer. Brachy is far more limited in its use, also... namely, it's been shown to be ineffective against higher grade disease, whereas radiation - external beam of any sort - retains efficacy. >> > The New York Times has posted the following questions in an article. >> > It [quoted text clipped - 56 lines] >> > its >> > Web site. |
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