In his recent NBER paper on inefficiencies and costs in the health care system, David Cutler provides a very good summary of the prostate cancer treatment problem, calling it the “poster child for overused care.”
Consider the treatment of localized prostate cancer (Perlroth et al., 2010). Almost all elderly men have cancer of the prostate. In many cases, however, the cancer grows slowly, and the person will die of something else before the cancer becomes fatal – or even clinically meaningful. Thus, ‘watchful waiting’ is a common strategy. In some cases, the cancer will grow rapidly and should be treated. However, it is not always clear whether a patient has a rapidly growing cancer or not.
There are a variety of different treatments for prostate cancer. In addition to watchful waiting, men may receive radical prostatectomy (removal of the prostate), brachytherapy (radioactive implants in the prostate), external beam radiation therapy, and intensity-modulation radiation therapy. Costs increase with the intensity of care. Costs in the two years after diagnosis average about $50,000 for watchful waiting and radical prostatectomy, about $68,000 for brachytherapy, about $78,000 for external beam radiation therapy, and about $96,000 for intensity-modulated radiation therapy.
Some clinical evidence has examined the effectiveness of these different strategies. The results suggest that the therapies are approximately equally efficacious in men aged 65 and older, the most common group diagnosed with localized prostate cancer. In particular, there is no evidence that the newer and very expensive radiation therapies have better outcomes. There is some evidence of adverse side effects with surgery – impotence and incontinence are common outcomes – making watchful waiting even more appropriate for many men.
Still, rates of invasive treatment remain high. Only 42 percent of elderly men with prostate cancer receive watchful waiting. One-third receive a radical prostatectomy, 15 percent receive brachytherapy, 1 percent receive external beam radiation therapy, and 5 percent receive intensity modulated radiation therapy. A final 4 percent of patients receive a combination of intensive treatment – which has not even been explored in the literature. Perlroth et al. (2010) conclude that savings of $1.7 to $3.0 billion annually would be realized by having all Medicare patients receive guideline-concordant care.
Patient preferences are not a major part of the variation in treatment. Sommers et al. (2008) show that patients differ in their preferences for side effects and risks of metastatis, but these preferences do not predict the therapy a patient receives. Rather, patients get referred to a particular type of specialist, and this specialist then recommends the therapy that they judge best. Thus, patients who see only a urologist most frequently undergo a radical prostatectomy, while patients seen by a radiation oncologist undergo some form of radiation. (© 2010 by David M. Cutler.)
I do not think there is any reason to believe that most patients who see a urologist (or a radiation oncologist) are more in need of or better suited for radical prostatectomies (or radiation therapy). It’s far more likely that therapy received is a function of patterns of referral and practice. That randomness may be good for research but it’s not good for patients.
Perlroth, Daniella J., Dana P. Goldman, Alan M. Garber, “The Potential Impact of Comparative Effectiveness Research on U.S. Health Care Expenditures,” Demography 2010 (in press).
Sommers, Benjamin D., Clair Beard, Anthony V. D’Amico, et al., “Predictors of patient preferences and treatment choices for localized prostate cancer,” Cancer. 113(8), 2008, 2058-2067.