Why don't we hear more about this?

What is the advantage for doctors or radiologist to push their patients into agressive treatment? I've read some posts detailing cost of certain procedures, however do we know what the net profit the doctors make? Do they make more net profit in treating a patient  aggresively (surgery, seeds, radiation) , or do they make more profit in following an AS patient or advance PC patient for 10 to 15 years, or even make more profit by writing a book? I don't think we have does numbers.

If I was a doctor with a main focus on making money only, I would not push my patients into treatment right away, I would push for AS , see them every six months, have annual or semi annual blood test, scans and biopsies, then once I have taken their money for several years push them into treatment. Thats how you make money.  

   

Over time, the patient gets educated, informed and empowered and learns that many (not all) low risk prostate cancer cases are indolent and never need treating at all and pushes back...then the surgeon loses out on the big bucks.

We see patients get rushed into aggressive treatment all the time...

Then one has to assume that a doctor make more money in one surgery then following a patient for several years. Is there any data out there that confirms this?

 

Yep, my uro/surgeon has seen me a min. of 50 office visits, and did 8 operations on me within a 2 year window, 2 of them being major surgery. I am too well known in his offices, we are all on first name basis, lol.

We just got back from a weekend at the family farm in Hoosierland and found this interesting thread. 

My R. N. wife and I had an animated discussion about AS and overtreatment as we drove thru Chicago toward Indiana last Friday afternoon (actually, "driving" is a misnomer.  We were pretty much sitting still on the Edens and Kennedy expressway).  I'll admit, she made me think when she finally stared at me and asked, "And what would you advise our son to do if at age 40 or 45 a PSA test led to a biopsy, which showed "low risk" cancer. 

I'll admit, at that point theoretical considerations flew right out the car window, and I had to answer, "I'd advise him to get treated, and to strongly consider surgery as his first option at that age.  He and his wife have four young kids, and his first consideration should be staying alive and trying to become cancer free."

After my experiences of this last year, I would not want my son to be that "one in a hundred."  I would talk to him about the arguments favoring active surveillance, but I would be encouraging him to choose the surgical option.

Clocknut,

Interestingly, I had the same thought process last night about my son: what if he was diagnosed with biopsy-detected low-risk and likely indolent prostate cancer. I think that there was a time in my journey where my knee-jerk reaction would have been to encourage him to rush into treatment, but I've learned too much about prostate cancer now and my perspective has changed.

I wouldn't wish an unnecessary prostatectomy upon anyone, and so my sage advice at this point would be to slow down, take your time, continue to watch it closely as you undergo further tests to further validate a treatment decision one way or the other, understand that you have a large "curative window" during which if test results continue to show favorable results there is essentially no risk to defer treatment, change your diet and exercise patterns, and see if you can avoid an unnecessary aggressive treatment altogether. Biopsy-detected indolent prostate cancers come and go, and if they stay our lifestyle (diet, exercise, stress reduction) can influence whether they progress or not...I didn't realize that so clearly when I was a noobie.

Casey59 said...

...I didn't realize that so clearly when I was a noobie.

clocknut, I'm not sure which part of the above sentence you thought was directed at you...as for me, I consider myself bright, well educated and thoughtful, but today I look back on my first several months after diagnosis and realize how lucky I was to have gotten good outside advice from a wise patient about 2-years ahead of me, and to have eventually made a decision which was appropriate to my case because, in hindsight, I really understood relatively little about prostate cancer...although at the time I probably knew more than the average patient.

But I think your comments about men being "psychologically suited for AS" strongly reiterates the point I've previously made about the communication challenge which exists today.  The challenge is diminishing over time as increasing amounts of evidence on the safety of AS gets published and more doctors step forward in support of AS, but even today up to 20 or 30% of men in AS programs drop out without signs of progression...largely attributed to the psychological stress.

The words I've previously used:

Patients hear the word “Cancer”  and want definitive treatment.  The word “Cancer” evokes a response which is disproportionate to the natural history.  It is a communication challenge to overcome this…to explain why an aggressive treatment might not be the best choice.

My son is younger than yours by 20 years.  I think things will be quite different not too many years down the road, and many will look back with an "Invasion of the Prostate Snatchers" perspective...and by then we will be aggressively treating men with aggressive PC, and not aggressively (over-)treating men who don't have aggressive PC.

 

Casey, let's just pray that your son and mine, and all of our sons, never have to confront this particular challenge.  I'm the first in my family history that I've been able to find, and I hope I'm the last.  Like you, I hope medical science quickly progresses to the point where PCa, and all cancers, can be successfully treated. 

In a way, the whole AS question is academic for me. I was never a good candidate for it, so I was happy medical science had reached the point where they could successfully "snatch" my cancerous Gleason 7, grossly oversized prostate. 

Still, I personally find it hard to believe that any doctors are eager to "snatch" anyone's prostate.  Looking at it from a doctor's position, I can imagine how unsettling it must be to encourage AS, knowing that a certain number of your patients are inevitably eventually going to hit you with a lawsuit claiming bad medical advice, and that many juries would probably find in their favor, even if you did the medically "correct" thing.  It's a challenging decision both for the doctor and for the patient.

I hope some day we meet at one of the Chicago area events.  I would enjoy that very much, I think.

I prefer "newbie" to "noobie"... . 

Tudpock (Jim)

Ralphs original post was about why not more psa screening. The simple answer is total costs to society.
Currently 227,000 men are Dxed with PC. To achieve this DX rate , 880,000 will be biopsied at a cost of $880 million and treatment costs of nearly $9 billion ( 227,000 X $40,000). Throw in another $2 billion for psa testing and we have a cost of nearly $10 billion annually to effect about a 5,000 drop in death rate. To look at this another way, we spend about $10 billion to save 5,000 lives or about $2 milllion per life saved.
As every operations manager knows that costs increase exponentially to effect a small increase in detection. To drop the death rate an additional 5,000 would most likely cost an additional $30 or 40 billion and most likely $150 billion to drop it another 5,000.
It is a shame to lose even one life, but it simply gets to the point that the cost to save one incremental life becomes so great that society as a whole cannot afford it. We currently spend 18% of GDP on medicine and the rate is increasing. Other developed countries with better life expectancy than the US spend about half that amount. It is easy and moral to say that every man should get a psa test and every detection should be treated. If we did this for every disease we would be bankrupt as a society. You can argue the numbers, but the premise still holds.
JT

clocknut said...
We just got back from a weekend at the family farm in Hoosierland and found this interesting thread.

My R. N. wife and I had an animated discussion about AS and overtreatment as we drove thru Chicago toward Indiana last Friday afternoon (actually, "driving" is a misnomer. We were pretty much sitting still on the Edens and Kennedy expressway). I'll admit, she made me think when she finally stared at me and asked, "And what would you advise our son to do if at age 40 or 45 a PSA test led to a biopsy, which showed "low risk" cancer.

I'll admit, at that point theoretical considerations flew right out the car window, and I had to answer, "I'd advise him to get treated, and to strongly consider surgery as his first option at that age. He and his wife have four young kids, and his first consideration should be staying alive and trying to become cancer free."

After my experiences of this last year, I would not want my son to be that "one in a hundred." I would talk to him about the arguments favoring active surveillance, but I would be encouraging him to choose the surgical option.

That's great. I think most of us feel that way about ourselves let alone our children.

Regarding the "newbie" thing, it's laughable. Those that throw around that hostile and certainly counter productive term (edited, rules violation Rule 4- flaming, or provoking argument) I cannot see who used it, or in what context, but I imagine it's (edited)

Seems like every other topic here turns into an endorsement for AS (edited) I think AS surveillance was great for someone like my grandfather.

The point of this thread was informing patients of their situation. Then it's up to the patients to choose their path.


davidg, I edited out some provocative language in your post, I think you didn't read close enough to understand just what the discussion was about newbies. In any case, your post could be viewed as an attempt to reopen an old argument without any benefit of the goal of support, help, or info. James C.

Post Edited By Moderator (James C.) : 4/11/2011 11:32:45 AM GMT

JohnT, you've helped to shed light on the "Titanic & iceberg" economic reality. Without intending to incite any politics into this discussion whatsoever, I think everyone knows that significant change in our health-care system is coming not too far down the road...the trajectory we have been on is unsustainable. We feel the rumbling of an earthquake but none of us know exactly what things will look like after the quake hits. One thing, however, is clear--overutilization of fee-for-service resources is a huge problem in American health care and is a major target for health-care reformers now and in the future.

It is problematic that most patients in the US present with low-risk PC disease and many of these men have very little to gain from treatment, yet almost all are treated. Doctors are programmed to treat, trained to treat, paid to treat.

My crystal ball sees a future when doctors are paid for value. In the short term, however, it is more likely that they will be paid by a diagnosis; in other words, instead of being paid for treating the prostate cancer, they'll be paid for managing the disease. I can feel the rumbling...

Hi Casey,
The over diagnosis and over treatment current figures have been generated by computer models and have a wide range (15% to 85%) depending of what model and definition is used .

In Tyrol, the experiment in which a high percentage on men were screened AND treated, the figure for over treatment was 8.7%. This figure from a real experiment does not fit the picture of those that claim with incredible certainty that those over treated would have never been affected by their disease in their lifetime. How do they know this when the natural history of prostate cancer is not well understood?

Actually the natural history of UNTREATED prostate cancer has been written in the Scandinavian countries prior to the commercialization of the PSA test. Why not learn from history? There, men diagnosed at age 60 or under had an 80% PCa mortality. How is that for indolence?

Those that talk about the harms of treatment tend to ignore the harms of PCa progression. PCa progression tends to be slow, but it can be variable and become aggressive. Why do we believe that invariably those low grade cancers never progress? Why if we have been over treating so many men unnecessarily for years, so many currently fail treatment?

Yes, there is over treatment, but the solution is not a simple one with the current crude diagnostic tools they currently have and with no super, specific and sensitive marker in the pipeline. There are too many men diagnosed with advanced disease. I see them at the support group level all the time...