The Struggle to Find Straight Answers about Prostate Cancer Treatment

It wasn’t so long ago that even the doctors who were bad businessmen could still maintain a profitable practice.  Back then, the average doctor’s income was high enough to keep the clinic doors open, even when wasteful and inefficient business policies were employed.  These days the modern doctor is forced to track his finances a lot more closely.  Running an office is expensive and profit margins are tight.

Patients often assume that the business aspects of medicine can be disregarded when sitting down with a professional to discuss the selection of prostate cancer treatment.  This assumption is highly naïve. Consider that no treatment can be offered unless your physician first makes a huge personal investment of time and money being trained to deliver a specific type of therapy.  Secondly, consider the type of infrastructure investment required to offer robotic surgery, IMRT or proton therapy. Whether the physician you meet has made that investment personally or if he is only an employee of the firm, there is a strong motive to sign up new patients.  Only a constant flow of paying customers brings in the revenue necessary to pay the mortgage.  

Most of the time when I query patients about the type of sales approach used when they visit other treatment centers, they describe it as a “soft sell.” Doctors aren’t stupid.

 They are well aware of the numerous centers competing for patients.  Physicians who present a “listening ear” are far more credible and convincing than a doctor who adopts a dogmatic, hard-sell type of approach.  Even so, I still am shocked to hear about an occasional doctor who uses blatant scare tactics:  “You better hurry up and decide before the cancer spreads” and “if you don’t start immediately you’ll be dead in two years.”

Patients have the greatest difficulty getting straight answers when trying to determine the feasibility of doing active surveillance.  Everyone seems to know that some types of prostate cancer might be safe to watch but where do you draw the line?  Grade 6 with one core only?  Two cores?  Multiple cores? What about small amounts of Grade 7?  It’s hardly surprising if we encounter doctors that are “less comfortable” with the idea of monitoring. Reimbursement is tied to treatment. Is it reasonable to expect these doctors to expend tireless hours trying to convince frightened but ill-informed patients that their cancer is harmless?  Doctors and the patients alike are happier with the idea of rushing into radical treatment.

Data from a large study called the “PIVOT Trial” published in the New England Journal of Medicine is particularly relevant when addressing the question of monitoring versus immediate treatment.  In the PIVOT trial 731 men volunteered for watchful waiting or immediate radical prostatectomy based on a coin flip.

 The goal of the trial was to determine if immediate surgery would prolong life compared to watchful waiting.

The men in the study had a median PSA of 7.8 and a fourth of the men had cancer big enough to be felt on a finger exam. The spread of patients across the three risk categories—low, intermediate and high—was what might be expected in this modern era: 43% were low risk, 36% were intermediate risk and 20% were high risk.

After 12 years, the low risk group, as would be expected, showed no improvement in survival with immediate surgery. The surprising finding was that men with intermediate risk also failed to show any survival benefit with immediate surgery. To round out the study findings, immediate treatment did improve survival in the men with high risk disease.

How can we incorporate this important research in counseling men contemplating active surveillance versus immediate treatment? Should we consider all men with intermediate risk prostate cancer to be potential candidates for active surveillance?  The conservative approach is to recommend active surveillance to men with favorable types of intermediate risk disease.  “Favorable” intermediate risk can be defined as Gleason 3 + 4 = 7, not Gleason 4 + 3 = 7, a PSA less than 10, a limited number of core biopsies positive and an imaging study such as a multiparametric MRI without aggressive features.

Men with newly-diagnosed prostate cancer quickly learn there is fierce competition to sign up patients for treatment.  Surgeons recommend surgery and radiation doctors recommend radiation.  Proton, Cyberknife and seed implant doctors also speak convincingly about their particular specialty as well. One old pitch deserves mention:  “Salvage radiation is feasible after surgery but salvage surgery after radiation is not.”  Basically the implicit message is that surgery and radiation are indistinguishable, therefore, one should prioritize the backup plan.  This outdated argument actually had merit fifteen years ago when radiation cure rates were lower than surgery.  These days, however, men should know that cure rates are as good as or perhaps better with radiation.  The best results come from “getting the job right the first time” rather than planning for failure.   

Treatment selection for newly-diagnosed prostate cancer is also influenced by factors like age and the desire to maintain sexual potency and normal urinary control. The stakes are high because many treatment-related side effects are irreversible.  It would be wonderful to have an even-handed, unbiased physician counselor to provide support.  Unfortunately, the business environment has become far too competitive to allow patients to indulge in such wishful thinking.

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