Ultimately, the lively debates over surgery vs. radiation or IMRT vs. proton-beam therapy obscure the fact that for most low-risk prostate cancers, the best treatment is no treatment; most low-risk patients should be on active surveillance. But again, reimbursement incentives are aligned against doing the right thing: We need a CPT code for surveillance of malignancy, if we want to fix the critical problem of overtreatment. Prostate cancer is not unique in this need: Oncology is now beset with new epidemiologic and public health problems arising from overdiagnosis in an era of widespread imaging and advanced diagnostics. The health care system needs incentive structures that recognize the nuances of diagnosis and risk stratification, and that do not drive maximal – and maximally expensive – therapy for all patients at all times.
Strident advocates for particular technologies run the risk of winning pyrrhic victories over other modalities but ultimately helping lose the broader war on prostate cancer. Whether or not the U.S. Preventive Services Task Force’s draft statement against prostate cancer screening becomes its final recommendation, the writing is on the wall that the broader medical community’s tolerance for overtreatment is, appropriately, dissipating quickly. If the treating community – urologists, radiation oncologists, and medical oncologists – does not tackle overtreatment more aggressively, and target treatments to individual patients’ tumor characteristics and comorbidities, there is a real risk that primary care providers will stop screening altogether, and much of the progress realized in recent years in prostate cancer mortality rates will be lost.
Conversely, for men with high-risk prostate cancer, arguments among modalities should yield to a paradigm recognizing these tumors as aggressive and potentially lethal, best treated with a combination of surgery, radiation, and systemic therapy – just like rectal, breast, and other malignancies.
Hopefully, one result of the many ongoing comparative effectiveness research efforts will eventually be a system that rewards outcomes rather than technology, although clearly more than research will be required to effect the needed reforms.
In the meantime, for treating clinicians to retain (or regain) leadership in setting the terms of the debate over prostate cancer, we need to demonstrate that we can routinely assess and report the long-term outcomes that matter most, engage patients fully in shared decision-making, target intensity of treatment to individual patients’ cancer risk and comorbidities, and prescribe interventions that are proved to be both effective and cost-effective.
Dr. Matthew R. Cooperberg is assistant professor of urology at the University of California, San Francisco. He disclosed having no relevant conflicts of interest.