ASCO GU 2013

Overtreatment of low risk prostate cancer: incidence in USA, cost, complications and implications

Dr Ayal Aizer – Dana Farber Cancer Centre, Boston, USA

Doctors, both urologists and radiation oncologists, prefer to administer the treatment that they’re capable of delivering and the data has shown that. So radiation oncologists like to give radiation; urologists like to give surgery. What we’ve found is that if you look at men who have a life expectancy of under ten years and they have a very early form of prostate cancer, we found that two out of every three of those men are being treated with radiation or surgery. And we think that’s an important finding because if you look at the risk of dying of prostate cancer at ten years in a patient who has very early disease, that risk is close to zero. So we have to really be wondering what benefit are we providing to these patients?

Is cost an issue when treating patients?

Treating prostate cancer is definitely expensive and, as you can see, it ranges, it ranges depending on the therapy that a patient undergoes. But when we did our analysis there was a difference of about $15,000 in five years between an approach that involved treatment versus active surveillance, and that’s an adjusted approach that accounts for all potential costs. So about 15,000 per patient and that amounts to about 30 million per year in the United States, money that could really be used elsewhere.

What sort of complications are you coming up against?

The prostate is in an area where there are so many vital normal structures around it that any surgery or radiation is going to have its complications. So urinary toxicity is a big deal, bowel toxicity is a big deal, erectile function is a big deal and as you can see, a very high percentage of these men are getting toxicity when they undergo either surgery or radiation, they’re both toxic in different ways. And active surveillance, which bypasses that toxicity and potentially gives patients an opportunity to maintain their quality of life, really should be utilised more in these situations.

What implications do these results have on screening?

That’s a great question. We feel that it ties into the screening issue nicely because we feel that if we were to use screening to identify people who truly have higher risks of prostate cancer and treat those people, that would be a much better use of screening than what we’re doing now which is we identify prostate cancer and the majority of the time, regardless of the risk of the prostate cancer, we are offering and administering treatment. If we were to use the screening to identify the high risk candidates, the high risk patients, and treat them appropriately and take these lower risk patients and use active surveillance, that would be a much better approach to screening.

It’s a complex debate and you can look at some of the data where people have been randomised to screening versus non-screening, particularly the studies that have been done outside the United States. And there’s no doubt that, if you look at those studies, that screening saves lives; it definitely saves lives. The question is, does it save enough lives to justify the toxicity that people experience when they are diagnosed with an early prostate cancer, for example, and undergo toxic therapies like surgery or radiation? Our feeling is that if we could use the screening, maximise the benefit of the screening in terms of saving lives, but not over-treating patients once we identify the early prostate cancers, that would be the best approach.

Are there any guidelines coming out of the study to prevent doctors from over-treating patients?

There are guidelines already published, for example the NCCN guidelines, which state that if you think that a patient is not going to live for ten years and they have low risk prostate cancer, then really they should be monitored with active surveillance. I think some of the takeaways here is that those guidelines are not being followed in general by the community. I think it suggests that we need to do a better job of estimating life expectancy as physicians; the data says we don’t do a fantastic job in that regard. I think it shows that we need to really use multidisciplinary approaches to determine whether patients really need treatment; also we need to do a better job weighing the costs and toxicity aspects of the treatments we provide in order to really deliver the best care for our patients.

What advice would you give to clinicians?

What I would say is that when you have a patient who has low risk prostate cancer and he’s either old or has a lot of other health problems, we need to really strongly consider what benefit we’re providing them by giving them surgery or radiation. And we would strongly, strongly push for active surveillance in this population of patients, both to avoid toxicity and to decrease costs to the healthcare system at large.