Prostate Cancer: Studies in Appropriate and Necessary Care
Are we spending appropriately on cancer care? A panel of researchers and clinicians explored that question and more at the recent Health Affairs briefing on value, costs, and quality in cancer care, held in Washington, D.C.
For me, two studies stand out because they go to the heart of healthcare reform, namely the questionable utilization of, and spending on, healthcare, in this case prostate cancer. One study raises concerns about overtreatment, while another finds widespread inappropriate treatment.
Jacobs and colleagues* looked at the use of intensity-modulated radiotherapy (IMRT) from 2001 to 2007. They found that men whose prostate cancer was considered low risk (less likely to be a clinically significant cancer) were nonetheless as likely to receive IMRT as men at high risk. Their finding raises concerns about overtreatment with IMRT, which costs $15,000 to $20,000 more than standard therapies.
The study also raises the question: At what price is society willing to pay for small incremental benefits in outcome from highly expensive technologies?
“In the context of limited resources, does everybody deserve a Cadillac when a Buick is almost as good?” asked study co-author Bruce L. Jacobs. Price notwithstanding, Jacobs noted that several cancer centers are upping the ante. They have built or have plans to build facilities for proton beam therapy.
“History repeats itself. Are we experiencing the same phenomenon with proton beam therapy?” Jacobs asked. In handling promising new technologies, he urged, we need to strike a better balance between the promotion of new, yet unproven, technology with the risk of overuse. He did note optimistically that the use of radiation has decreased for both IMRT and three-dimensional conformal therapy among low-risk patients.
A second study found poor adherence to the National Cancer Network’s guidelines for imaging men with incident prostate cancer in the Medicare population. Using SEER program data (the Surveillance, Epidemiology, and End Results-Medicare linked database), Makarov and colleagues** found that more than 45 percent of men with low-risk prostate cancer underwent guideline-inappropriate imaging, and only two-thirds of men with high-risk disease had appropriate imaging evaluations.
Imaging use appears to be determined strongly by regional practice patterns rather than by medical indication. “Poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients,” Makarov warned. He and his colleagues concluded that healthcare organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.
A key take-home message from the Health Affairs briefing, echoed by many presenters, was that cost-control policies must selectively educate providers to change their behavior and reduce the use of unnecessary care, while still ensuring appropriate care.
Isn’t that what healthcare reform is all about?
Check out ACCC’s extensive online resources on Prostate Cancer programs in community cancer centers.
*Jacobs B, Zhang Y, Skoalrus T, et al. “Growth of High-Cost Intensity-Modulated Radiotherapy for Prostate Cancer Raises Concerns About Overuse,” Health Affairs. April 2012. Vol. 31, No. 4, 730-740.
**Makarov D, Desai R, Yu J, et al. “Appropriate And Inappropriate Imaging Rates for Prostate Cancer Go Hand In Hand by Region, As If Set by Thermostat,” Health Affairs. April 2012. Vol. 31, No. 4, 730-740.