Today's New York Times includes an article, on the business of prostate cancer treatment, that is certain to infuriate some, frighten others, and leave still others baffled.
The front-page story details recent criticism of and skepticism about the growing popularity of external multiple beam radiation treatment (called I.M.R.T.), even though several other well-accepted treatment options exist.
I.M.R.T. is what I received at Memorial Sloan Kettering Hospital when I was diagnosed with prostate cancer five years ago. Memorial Sloan Kettering is the institution that has conducted a large share of the early research on the therapy.
The treatment is described as a “pinpoint” because it attacks only the tumors themselves; CT scans build a 3-D computer map of the cancer terrain before the device delivers 40 or so targeted radiation treatments over 9 weeks.
I have already reported in this blog on various mainstream forms of treatment for my kind of prostate cancer (a Gleason of 6) which was large, but confined to two of the lobes of my prostate. These treatments include:
- Surgery (A prostatectomy)
- Seed implantation (All in one day, sometimes outpatient, sometimes inpatient)
- I.M.R.T. (Dozens of courses of treatment spread over months)
There are others (freezing the tumors; hormones; homeopathic, etc.), but those listed above are still the main ones used by 95% of urologists and oncologists. I chose I.M.R.T because I didn’t want to risk the side effects of surgery, and I couldn't stand the thought of carrying radioactive seeds inside me for a long time.
Looking back, I would still not do surgery, because the idea of even a day of incontinence worries me. But, I would go for the seeds, because I know more now, and I believe there would have been fewer side effects with seeds than I had with I.M.R.T.
However, the patient's perspective and motivations is not what the Times article is about. It is about whether increasing profit margins or optimizing patient care should be driving utilization of the therapy.
The technology behind I.M.R.T. is an expensive investment-- about $3 million, including compensation for the additional services of a radiation oncologist. The article raises questions about whether urologists and hospitals are recommending the treatment more than they should, based on its relative clinical merits. Instead of maximizing clinical benefits, the doctors and hospitals may be maximizing profits from the technique, which to me poses a conflict of interest.
If it were a simple matter to determine which treatment is “best” for patients not in serious danger of dying from prostate cancer – in other words, the majority of men who are diagnosed – that would be wonderful. But, that is not the case. It is far from simple to determine what is best.
Factoring in how much you can profit from the procedure, as a urologist or hospital, cannot possibly clarify the decision options.
If I.M.R.T does a safer, better job than surgery or seed implantation, it should be up to the insurance companies and Medicare to worry about cost. But, there are other factors to consider, among them the desire and wishes of the patient; the side-effects; the age of the patient – and on and on.
The fact is, despite the claim by most people in the field that “all treatments” provide a similar outcome, some treatments for some patients provide a different outcome.
And, what do practitioners mean by “similar outcome?”
Do they mean the patient will live longer?
Do they mean the cancer is gone?
Do they mean the same number and kind of side effects?
They mean, most probably, that the cancer is gone…which is a good thing, but doesn’t speak to the quality of life of the patient, both mentally and physically.
It should be noted (and the Times article does so) that most people who received one treatment or another are pleased with the outcome. This is a little like Mac enthusiasts praising Mac, and PC enthusiasts praising PC. It depends on which computer you started with, say the experts.
I don’t know what the answer is for treatment of prostate cancer. I do know that if doctors are actually recommending I.M.R.T. because they benefit from it financially, that’s a moral outrage. On the other hand, if they do so because they believe it’s best for their patients, that’s legitimate. How do we separate the sheep from the goats?
Frankly, I don’t know, so I suppose it’ll be up to the regulators, the insurance companies, and the ethicists to sort this out – because the votes are still not in on what’s the best for each patient.
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Published On: December 01, 2006