The decline of Brachytherapy

It's pretty unbelievable that this actually happens, but not really surprising,

Reading this makes me glad treatment in the UK is free to the end user. I would like treatment (my biopsy result a week from Monday) that is the best for me not the one that funds a new car for someone.

The perverse economics of health care are real, and they extend far beyond PCa treatment. Nobody involved has any incentive to lower costs OR improve treatment, except, of course, for the patient. I certainly don't know how to fix it, but having experienced it personally, I know it's fundamentally broken.

Is it fixable? Can we even agree on what the problem is?

Based on Yooper's synopsis of this article/study (?) it appears to me that "The Decline of Brachytherapy" (title of this thread) and prostate surgery has a lot to do with:

1. Medical professionals are now turning to AS for primary treatment of indolent PCa, and
2. A superior technology (IMRT and other non-invasive radiation treatments) replacing outdated technologies (brachytherapy and surgery). Guys are beginning to choose non-invasive radiation treatments, it is not being forced on them by the US Medical Industry. Fortunately, in the USA you can still make choices concerning your treatment, and you can choose a 21st century treatment .... for better or worse.

To me, both of these trends are huge positives and not an indictment of the US Medical Industry. As an investor, I would not invest in PCa surgery or Brachy .... I would invest in AS and non-invasive radiation technology. So long buggy whip ... hello horseless carriage.

Brachytherapy and IMRT/IGRT...........one is not better than the other. They are different. And can, in the right situation , be used for mono-therapy.....and they can be combined for complimentary therapy. I had both with high risk PCa because I needed both. Certainly the HDR Brachytherapy was great for the prostate, but in no way could it be used for the pelvic lymph nodes. Only the IMRT could help there.

The point is that we are very fortunate to have many effective treatment modalities. I wish we could stop the binary system of "one is good and the other is bad" and get to the point where they are used commensurate to their respective effectiveness given the specific situation presented by each individual patient. It is very clear that at the present time there is no one best treatment for all PCa. It is a multi-focal disease and thank goodness we have a variety of treatments that be fine tuned to meet the specifics of each afflicted man.

The opening hypothesis is correct but incomplete according to the American Brachytherapy Society. From an earlier post:

The American Brachytherapy Society (ABS), in their Winter 2014 newsletter, presents their viewpoints on why it is declining. Read the newsletter yourself HERE, but I’ll summarize. They list the following factors:
· An increase in the number of robotic prostatectomies
· Advanced radiation delivery systems such as IMRT, SBRT and protons
· Higher reimbursement with IMRT compared to brachytherapy
· Suboptimal BT volumes procedures for radiation oncology residents that correlates to BT declines in academic centers
This last factor, a 48% decline in BT from academic centers, is significant in that it provides insight on the future of BT. In response, one might expect to see increased advertising from the independent, community based BT centers in an effort to protect and prolong the life of their investment.

The article “The rise and fall of prostate brachytherapy” (on PubMed) drills further into the BT trends, reporting that the largest demographic shifts are the declines in usage amongst younger men (inversely correlated to those on Medicaid), men more recently diagnosed, and increased PC case risk. Discussion at the 2014 ASCO meeting (HERE) further exasperated the BT trends amongst low-risk men, highlighting the notion that AS (non-treatment) of low-risk men is increasing, which was the lifeblood of the BT practice. More men with low-risk cases are realizing that they should treat PC as a chronic illness, not entirely unlike high cholesterol or diabetes, instead of super aggressive therapies. AS trends seem to be going up at about the same rate as BT rates are going down...there is a correlation, although this does not demonstrate causation.

NK, not sure what you meant by "opening hypothesis is correct but incomplete?"

In any event I agree with most of what you've posted - however this conversation / topic is not complete without the main point that I brought forward:

From the U.S. Government Accountability Office, www.gao.gov

Transcript for: Medicare Prostate Cancer Treatment Costs

"Self-referral—which is when a doctor refers a patient to an entity or a specific treatment in which the doctor has some kind of personal financial interest—is generally prohibited under Medicare rules. However, an exception allows doctors to self-refer prostate cancer patients to a certain common but costly treatment. A team led by James Cosgrove, a director in GAO's Health Care team, recently examined the effects of self-referral on the types and costs of treatment for
Medicare beneficiaries."

"We saw large differences between self-referrers and non self-referrers and especially among the group of providers who switched between the two. We can only conclude that it looks very much like financial interests play a role in the type of treatment that a beneficiary with prostate cancer actually receives. We're recommending that Congress consider mandating that physicians who
self-refer for IMRT disclose their financial interests to their patients. So that beneficiaries, when they're considering the advice that they get from their doctor about the kinds of treatment options
that they have available, know up front that their physician may have a financial reason for suggesting one course of treatment versus another."

"Over this period, (2006 to 2010) the number of prostate cancer–related IMRT services performed by self-referring groups increased from about 80,000 to 366,000. Among all providers who referred a Medicare beneficiary diagnosed with prostate cancer in 2009, those that self-referred were 53 percent more likely to refer their patients for IMRT and less likely to refer them for other treatments, especially a radical prostatectomy or brachytherapy."

There is a direct correlation between this huge increase in the use of IMRT and the decline of brachytherapy. The fact, not hypothesis, of the matter is, is that this is a very real issue, is being investigated by the U.S. Government Accountability Office, and has been brought to Congress.

Yooper, thanks for dragging this back to the basic topic, which is really the elephant in the living room about the US health care system. I've thought about this a lot, and the medicare angle is huge, and while many of us are not on medicare, the rules medicare establishes drive a great deal of the rest of the system.

I'm more and more convinced that the answer lies in getting away from fee-for-service and adopting one of several models where doctors are salaried professionals who are judged by quality of patient care and outcome, not financial outcome for their clinic, medical school, or hospital.

The newest therapy is not always better than the old one.

Steering patients to treatments that are the most profitable has always been a problem. The main issue is human nature, a farmer will produce the crops that have the most profit for him, not because he wants to feed the world. The natural pricing of services based on supply and demand is an efficient method of allocating resources and insure that the costs of a service match closely with what one is willing to pay for them.
When prices are set by insurance companies or the government it corrupts the fee flow of information that natural market prices provide. Surgery costs about $25k, LDR Brachy about $13K, IMRT about $45K to $60K, Proton about $75K. If they all achieve the same cure rates and SEs and patients were able to choose based on the price they were willing to pay out of their own pocket I think we would see a drastic shift in the % of patients choosing various treatment options.
Should we really be surprised that providers try to shift patients into the more expensive options. In our current system where a 3rd party pays for services, price is not a major consideration in a patient's decision making, but is a major factor for a provider of that service.

It is important for patient to get 2nd opinions from providers THAT ARE NOT IN ANY WAY CONNECTED TO THE DOCTOR MAKING A RECOMMENDATION OR PROVIDING A REFERRAL.

Wow, how is it I missed this thread!

As someone who has worked well over 40 years total in the health care system, and spent 36 years pouring anesthesia in surgery, I have occasionally expressed my awareness of bias in most groups including medicine/surgery, whether the ones recommending my treatment or the people doing studies about various treatments and drugs. In all cases, possible or even likely bias must be considered. I have been told by some that they do not share my cynicism in these matters, but the premise of this thread indicates that some other folks do.

It all gets back to the old saying that I have kind of claimed as BillyBob's 1st principle that governs most aspects of human behavior: If a man has a hammer, everything looks like a nail. And possibly, even more so the more hammers he has, or the bigger(as in big $) his hammer. He almost can not help it, it looks like a nail unless he can overcome self interest and human nature.

We need to consider possible bias in all advice we are seeking. For example, I have, in previous posts, given several examples of personal experience where something cheap and natural has helped me or loved ones, and it is obvious that the doctors involved either new nothing about it or knew and were not going to tell me. To repeat probably the first example I gave: the Uro who finally recommended zinc for me, which actually helped quite a bit. The question that naturally arises: was he ever going to volunteer that knowledge to me if I had not been badgering him for something else, AND if I did not know him personally and work with him in surgery several times a week? After all, what he finally suggested as a possible help was indeed a help, and it reduced me having to go to him for exams and repeat prescription antibiotics by 75-90%. He almost totally lost a paying customer, almost. From multiple times a year to every few years at the most. One can readily see that very much of that sort of thing would severely impact the bottom line. It could decrease how full his office was every single day. And this not unlike my daughter's experience with her need for antibiotics for UTI several times a year, essentially and quickly wiped out by a cheap alternative treatment. She has not needed antibiotics or the alternative treatment since, for years. But in that case, the doctor probably simply did not know. Who was going to tell him? Some drug rep?

Still, it is nearly impossible to know what to do about it. If we are not the experts ourselves, then we must figure out who is an expert and ask them. And that means we need to find an unbiased expert. Hopefully one whose livelihood or need of $ for a new vacation home or his new jet or new Mercedes for his wife will not influence his opinion and advice to us. Good luck on that! It is not impossible, but the financial considerations are sort of stacked against us.

But the financial incentive causing bias also works for us. It is the incentive for vast profits that funds cutting edge research. Some have been advocating more government control of medicine like other countries have. But many of us know of desperate people somehow finding the money and escaping over the border from Canada for treatments they needed NOW. And last time I was visiting Canada, on the TV news there was a story about a big battle that was brewing because the gov was allowing- or considering- people who could pay more to move to the head of the long lines. Groups for the poorer people were protesting this as being unfair. Now please, before any one from outside the USA shoots the messenger, all I am reporting is what I saw on the Canadian equivalent of the US nightly news. I can't speak to whether it was true or not. So, financial biases can cause an additional rock and a hard place for those seeking unbiased advice.

And don't we all know this? Isn't it comonly said around here that - even though surgery might well be what you need, still you don't ask ONLY a surgeon what you should do about your PCa?

Yooper, I have question about the definition of "self referral".

If we go to a Urologist and he suggests a Bx, and then if we have PC he suggests we allow him to do surgery pretty quickly, is that self referral? If it is, then isn't self referral the norm in most of medicine? Or does it have a different definition?

Halbert,
It's difficult but not impossible. I like the way my home and car insurance work. If I make a claim an adjuster is out the next day and determines what the insurance company will pay and prints me a check on his portable printer. I now have the choice of keeping the money and living with the problem or making my own arrangements to get it fixed by anyone I choose. I have never found a case where a service provider would not accept the amount of the insurance. If I choose I could pay more or less for the repair depending on what was important to me. I pay out of pocket for all minor repairs such as preventive maintenance. It's my responsibility if I don't change the oil and my engine blows up.
I always think of the case where my dog had cancer and needed surgery, radiation and chemo. The vet used interns at the local hospital who worked nights to supplement their income. Same doctors that work on you and me. The cost was $4500 for everything. If I had the same procedure from those same doctors using the same equipment it would have been $100 to $200k.
This is nothing but price distortion and it's the high cost of medical service that keeps people from getting treated, not availability. Vets have found a way to provide similar services at a fraction of the costs, and I can't buy into the argument that it costs $200k more to provide the same services on a human just because he's human. By the way, my dog lived 4 more years and died of old age.
It's a fact that the largest costs of medical services as a whole are in the last one or two years of life. Is it fair to society to allocate resources to extend the life of a 90 year old, because it means significant resources are taken away from younger people because those services will be priced well above what they can afford.
If our total medical costs were reduced by 50%, how many more people would get good medical service because they could now afford it? Most industrialized countries operate total medical costs at 7-8% of GDP while the US is at 18-19%. What are we getting for the extra 1.6 trillion dollars that we are paying? Our life expectancy is not greater nor are medical interventions more successful than in countries like Holland or France or Sweden. The fact is that 50% of our medical costs are wasted.
If someone wants to pay $100k for proton instead of $13K for Brachy that's his choice, but I should not have to pay for his choice through higher insurance rates or higher taxes.