By: Mike Steinberg, MD
Selecting a treatment for prostate cancer is increasingly complex. In an effort to help my prostate cancer patients navigate the complexities of this process, I routinely frame the discussion around these three rules:
Rule #1: If you listen to enough people you will hear just about anything.
Rule #2: You are at the mercy of the bias of the person you are talking to (e.g. doctor or other healthcare advisor), including me!
Rule #3: Ultimately, in the absence of randomized trials or other evidence proving one treatment is clearly better than another, the final decision for treatment is up to you, the patient.
In my daily practice treating patients at UCLA I do a lot of second opinion consultations for folks trying to figure out what to do next. When I tell the patient and their family Rule #1 I typically get a reaction that is best described as a sigh of relief. These patients have been subjected to a cacophony of opinions from other consulting physicians, well-meaning friends as well as the redoubtable internet. Patients (and their spouses) are just happy to know that their confusion is not because of some personal or intellectual shortfall, but instead it is because of the complex circumstance in which they find themselves. Most patients become quickly confused by the large array of treatment options available, particularly the complexities they face in the case of low and intermediate risk prostate cancer.
There is active surveillance, surgery (both open and the robotic variety), standard IMRT, permanent seed interstitial implants, High Dose Rate interstitial implants, Stereotactic Body Radiation Therapy - SBRT (also call SABR), and various combinations of the above as well as the investigational ablative therapies such as HIFU and so on. The bottom-line here for patients is that for many cases of low and intermediate-risk prostate cancer, the treatment outcomes, in terms of local control and cure, are basically the same for all of the options. The literature is clear on this issue. If someone tells you one treatment is definitely better than another in low or intermediate-risk prostate cancer, you are not hearing a medical fact, but the personal bias of the consultant.
That brings us to Rule #2 for patients with prostate cancer – biases. In medical science we classify the most reliable evidence (obtained through rigorous clinical trials) as “Level 1 evidence.” In the case of treatments for early stage low and intermediate-risk prostate cancer, we do not have this level of evidence for head-to-head comparisons between treatments (e.g. surgery vs. radiation therapy of any type). Instead what we have is large sets of historical data from different cohorts of patients who received one treatment or another. When we compare these various historical treatment groups of surgical or radiation therapy patients we find that patients of the same stage, Gleason grade, and age all do about the same – regardless of the treatment modality selected. Healthcare providers will of course have their own personal bias established through their years of training and experience. As everyone knows, if you are a carpenter you pound nails, so if you are a surgeon you operate and if you are radiation oncologist to give radiation therapy. And so it goes? Well, hopefully not.
Whether it is the surgeon, radiation oncologist, medical oncologist, or the primary care physician, I think their work should be informed by the Biblical quote, “Don't put a stumbling block in front of a blind man.” It is the role of the physician to lay out (1) the options for treatment, (2) the nature and rationale of the various treatments, (3) the possible side effects of each treatment (also called the morbidity of treatment), as well as (4) the expected probability for control and cure of the disease. Hyperbole in the form of exaggerated outcomes by a consultant should be suspected. Now there is a caveat. As in any profession, there are very good and not-so-good practitioners. This, of course, raises the question of how do you select an excellent clinician? That inquiry is worth its own blog post.
However, when it comes to bias, sadly I have to inform you that there is a particular kind of bias that is economically driven. It is the legal yet highly questioned practice of self-referral. Self-referral is the business practice in medicine in which a physician who makes the diagnosis for a condition also owns the technical fee of the treatment modality. This fee is the expense of the treatment not related to the professional fee, typically charged by a hospital or other business entity which is separate from the physician work associated with completing the treatment. In the case of prostate cancer the circumstance in question is when a urology practice also offers, for example, radiation therapy.
This is a health policy issue that is now hotly debated. Health services research has shown that when a physician owns the technical fee of a treatment such as radiation therapy, their patients are twice as likely to receive that modality of treatment. The Government Accountability Office (GAO) also investigated this concern and confirmed the finding. This is also true when it comes to the ownership of medical imaging, physical therapy, and pathology services. The US Government’s Department of Health and Human Services has estimated an additional $6 billion in cost each year is added to the health care bill for Medicare alone due to the practice of self-referral. The ostensible conclusion is that the economic incentive can cloud medical judgment and may skew medical advice. We would like to think that is not the case, but the data is irrefutable.
Interestingly, the GAO added that in the case of “limited multispecialty groups” (defined as having 4 or less specialists, including a urologist), there was the same increase in utilization of the treatment. The notion that a small multidisciplinary group is better for patients was debunked by the GAO study. This behavior is in contrast to the behavior of “true multispecialty medical groups,” defined as having 20 or more specialists, such as what is found in large clinics, medical groups, and academic medical centers. These large multispecialty groups did not show the dramatically increased utilization rates for radiation therapy as seen in others. Apparently, in the cases of these very large groups, the shared decision paradigm between the patient and physicians was not corrupted by economic incentives. Point is, the newly diagnosed prostate cancer patient is at the mercy of the bias of the physician they are talking to and the reason for this bias may be based on their training, experience, or, as we now know, even economic incentive.
This brings us to Rule #3. In the absence of randomized clinical trials proving one treatment is better than another, the patient with low or intermediate-risk prostate cancer is left with a number of treatment choices, each with slightly different side effects, time commitment, cost, time away from work, and so on. The patient’s decision in these circumstances should be based on his preference and perception of the possible side effects, time commitment, and possible disruptions to daily living associated with each treatment option. Finally, the patient should take into consideration the very personal notion that a particular treatment may just be a “fit” for him – his life style, his perception of risk, and efficacy of the particular treatment. It is through this kind of personal consideration facilitated by healthcare providers and family that the patient will make their best possible personal treatment decision.
About Dr. Steinberg:
Dr. Steinberg is Professor and Chair of the Department of Radiation Oncology at the David Geffen School of Medicine at UCLA. His professional career spans private, corporate and academic practice and is known for the development of multi-site radiation oncology care networks that are characterized by clinical excellence and community based clinical research. The UCLA Radiation Oncology network includes the department at Ronald Reagan Medical Center at UCLA, academically oriented community practices as well as Children's Hospital Los Angeles. Dr. Steinberg is on the PCRI Board of Directors; as well as the PCRI Medical Advisor.