Prostate Cancer Debate

A study appearing tomorrow in the Journal of the American Medical Association shows that doctors are using advanced treatments more often than ever before to battle prostate cancer, but whether that is good or bad is the subject of much debate.

According to the American Cancer Society, about 240,000 men will be diagnosed with prostate cancer in the U.S. this year, and nearly 30,000 will die from the disease. One in six men will learn they have the condition at some point in their lives.

The statistics paint a nerve-racking picture for millions of Americans, putting a national discussion about prostate cancer front and center. However, the new study, authored by Dr. Brent K. Hollenbeck, an associate professor of urology and director of the Dow Division of Urologic Health Services Research at the University of Michigan, shows that new, expensive technology is being used to treat men not likely to die from the disease.

Researchers examined Medicare data and discovered that among men diagnosed with the disease but unlikely to die from it, the use of advanced treatments, such as intensity-modulated radiotherapy (IMRT) and robotic prostatectomy, skyrocketed by 85 percent between 2004 and 2009.

Hollenbeck told Healthline that such treatments, which have all but replaced traditional methods, such as external beam radiation therapy and open radical prostatectomies, may do more harm than good. They also cost the healthcare system billions of dollars every year.

“Avoiding treatment, if possible, would be a reasonable way to go," Hollenbeck said. "For men at low risk of dying, if you treat them you potentially are incurring some side effects without benefits.”

Hollenbeck and some other doctors said that in many cases, "watchful waiting" is a better option than radical treatment. Sometimes, prostate cancer is very slow growing. Other times, it is not.

Because the disease is both frightening and well known, in many cases patients who receive a cancer diagnosis want to try everything possible to get the best prognosis.

“There needs to be a greater emphasis on identifying men who have low risk for the disease progressing rapidly and causing harm, to make sure they understand the treatment may be worse than the disease,” said Dr. Durado Brooks, director of prostate and colorectal cancers at the American Cancer Society, which helped fund Hollenbeck's research.

In an interview with Healthline, Brooks estimated that as many as 40 percent of men diagnosed with prostate cancer are good candidates for observational management. Yet, fewer than 10 percent opt for that approach.

Brooks said some doctors have called for re-labeling low-risk tumors as something other than cancer to help alleviate fear among patients and promote the "watchful waiting" approach.

Brooks also said hospitals often want to boast that they are better than the competition, so new technologies are aggressively marketed to the public without proof of their effectiveness. “We're treating way too many prostate cancers too aggressively,” he said.

Dr. Howard Sandler, chair of the Department of Radiation Oncology at Cedars-Sinai Medical Center in Los Angeles, told Healthline he is not surprised by the study's findings. However, he does not dismiss the benefits of new technologies for prostate cancer treatment.

“While Hollenbeck's work shows a growth in more specialized treatment techniques, the motivation for the adoption of perceptibly better techniques is probably in the patient's best interest,” Sandler said. “While the study suggests that there can be financial motivation, I’d suggest that we look to Canada, with a single payer system and no financial motivation to apply more complex techniques. Canadian radiation oncologists routinely use IMRT for the management of prostate cancer simply because they believe it is a better technology for patients.”

Hollenbeck does note in his study that there is the potential to underestimate the severity of cancer in some patients based on a prostate biopsy, or tissue test.

“This uncertainty of prediction enters into the discussion between one physician and one patient—the patient looking for certainty and the physician unable to provide guarantees," Sandler said. "Importantly, the physician may recall another clinical situation in the past—perhaps a patient who was felt to have mild disease, but ultimately this was underestimated and disease progression and cancer death occurred.”

Bill Palos, a prostate cancer survivor and Illinois regional director for Us TOO, a non-profit group that advocates for people with the disease, told Healthline that while there is some merit to the new study, to do nothing about a prostate cancer diagnosis is wrong. He also expressed concern that the new study might encourage insurance companies to not pay for screening exams or certain treatments.

Palos lost his father, two brothers, and a nephew to the disease. He stressed the importance of semi-annual exams beginning at age 40 for people with a family history of prostate cancer. In this case, knowledge is decision-making power.

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