ANN ARBOR, Mich. —For men with a low risk of dying from their prostate cancer, advanced treatment options may offer little to no benefit, yet more and more patients are opting for these procedures.
A new study from the University of Michigan Comprehensive Cancer Center examined Medicare data between 2004 and 2009 for men with prostate cancer whose disease was low-risk or those who were at a high risk to die from other causes. The researchers found that these men increasingly underwent advanced treatment options, such as intensity-modulated radiotherapy and robotic prostatectomy.
Among men with low-risk disease, the use of advanced treatments increased from 32 percent to 44 percent, the study found. Similarly, in men with a high risk of noncancer mortality, the use of these procedures increased from 36 percent to 57 percent.
The results of the study, which were published online Tuesday, June 25, in the Journal of the American Medical Association, suggest that potential overtreatment of prostate cancer is increasing even at a time of greater awareness about the sometimes indolent nature of the disease, says senior author Brent Hollenbeck, M.D., associate professor of urology at U-M.
Patients who undergo more aggressive treatments instead of conservative watch-and-wait management are more likely to experience side effects and long-term quality-of-life issues stemming from the treatment, Hollenbeck says.
“Even during a period of enhanced awareness of overtreatment, it appears that the use of these technologies gained in popularity,” Hollenbeck says. “Not only do these procedures offer very limited benefits to this group of patients in terms of survival, they also are significantly more expensive than prior treatment options, amplifying the economic implications of potential overtreatment.”
Hollenbeck says there are several dynamics that might explain the findings. Patients and physicians are sometimes hesitant to embark on an observational treatment plan when an advanced procedure may cure the disease, he says. Additionally, the stress and anxiety of living with cancer can be overwhelming for some patients.
“While those concerns are valid, the outcomes of men with low-risk disease who follow an observational management plan as opposed to procedural treatment are well-established,” Hollenbeck says. “In addition, the financial incentives to do these procedures, through things like fee-for-service reimbursement, may simply be too strong to overcome.”
More research and policy changes are needed in order to shift the current treatment patterns for men at low risk of dying from their prostate cancer, Hollenbeck says. He points to the Surveillance Therapy Against Radical Treatment, or START, research trial as a valuable tool that will further explore the effectiveness of radiation, surgery and active surveillance for low-risk prostate cancer.
Although terminated due to poor accrual, the results from that study aren’t expected for another five to 10 years. In the interim, Hollenbeck suggests that changes in the delivery system and payment might be effective.
“We need policy changes that help curtail the excessive use of advanced treatment technologies among patients who are least likely to benefit,” he says. “For example, value-based insurance design discourages the use of services when their benefits do not outweigh the costs. Things like this can help eliminate the overuse of advanced treatment options when patients stand little to gain.”
Additional authors: Bruce L. Jacobs, M.D., M.P.H.; Yun Zhang, M.D.; Florian R. Schroeck, M.D., M.S.; Ted A. Skolarus, M.D., M.P.H.; John T. Wei, M.D., M.S.; James E. Montie, M.D.; Scott M. Gilbert, M.D., M.S.; Seth A. Strope, M.D., M.P.H.; Rodney L. Dunn, M.S.; David C. Miller, M.D., M.P.H.
Citation: “Dissemination of Advanced Treatment Technologies Among Men at Low Risk of Dying From Prostate Cancer,” Journal of the American Medical Association (2013)