Why Medicare Is Confused About Prostate Cancer Treatment

Not enough is known about the effectiveness of prostate cancer treatment. That fact, among others, prevents Medicare from making decisions about how to evaluate the available options. Susan Heavey in Reuters yesterday (h/t Kaiser Health News):

There is not enough evidence to sort out the effect of various radiation treatments for prostate cancer patients, especially newer, so-called focused radiation, an advisory panel told the U.S. Medicare agency on Wednesday. …

In looking just at radiation therapy, the advisers lamented the fact that just a handful of studies have been done and that most don’t follow patients long-term for at least five years. …

Panelists were split over whether strict, randomized controlled trials, patient registries and other types of informational gathering were most needed.

Many urged various medical groups to band together to compare all types of treatments, not just radiation, to each other — also known as comparative effectiveness research. …

Marcel Salive, head of the CMS’s division that oversees prostate cancer coverage, said … that the overall lack of data on radiation would likely cause “a real difficulty in drawing conclusions” and make it tough to make any nation-wide coverage decisions.

So, Medicare (CMS) can’t make a decision due to lack of information. Not enough studies have been done. What the article didn’t say is that randomized trials are hard to do in the case of prostate cancer, or in many other cancers. Individuals often don’t want to be randomized and recruitment is challenging (Ford, et al., Cancer, 112:228-42). Sometimes participation rates are as low as 15% (Wilt, et al., Contemporary Clinical Trials 30: 81-87).

This is a classic case where observational studies can help and may be preferable to recruitment-challenged trials. At least two funded by NIH are underway. I’ll have more to say abut this later. Stay tuned.

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