The proportion of US men with early, slow-growing prostate cancer who
received robotic surgery and other expensive treatments increased between 2004
and 2009, according to a new study.
Researchers found that use of those therapies also rose among men who were
unlikely to die from prostate cancer because they were sick with other chronic
diseases when their cancer was diagnosed.
"You can't get at what the right rate (of treatment use) is from our study,
but what we did find was treatment with these advanced technologies increased
over the past decade, and was fairly common," said Dr Brent Hollenbeck, who
worked on the study at the University of Michigan in Ann Arbor.
Evidence has been building that a wait-and-see approach might be most
effective for men with low-risk prostate cancer that may or may not progress,
rather than scheduling surgery or radiation right away.
But both doctors and patients have been hesitant to adopt that strategy, also
known as watchful waiting or active surveillance, researchers said. "There's no
incentive for (doctors) to do it, because there's no real payment, and it's very
complicated. It's not easy to do active surveillance," said Grace Lu-Yao, who
studies prostate cancer treatment at Robert Wood Johnson Medical School in New
Brunswick, New Jersey.
"What's more, some patients may just feel they'll go with the most
advanced technology and get rid of the cancer, so they'll feel more secure in a
way," she said.
Hollenbeck and his colleagues analysed data on about 56 000 older men
diagnosed with prostate cancer and covered by Medicare, the government's health
insurance program for the elderly and disabled. They found that among men with
low-risk cancers, use of high-end treatment -- including robotic surgery and
high-precision radiation, known as intensity-modulated radiation therapy --
increased from 32% in 2004 to 44% in 2009.
Likewise, the technologies' use among men with other serious health problems
increased from 36% to 57%, Hollenbeck and his colleagues reported in the Journal
of the American Medical Association.
Those high-end treatments largely replaced the use of older therapies, which
became less common, the researchers found. Close to half of men diagnosed with
low-risk cancer across the study period took a wait-and-see approach.
Impotence and incontinence
According to Healthcare Blue Book, prostate removal costs about $13 000 -- and
robotic surgery usually adds to the price tag. Treatment also comes with a risk
of side effects including impotence and incontinence.
"In someone who stands to benefit less, when there's no clear advantage to
treatment in terms of preventing death from prostate cancer, the cumulative side
effects of the procedure may outweigh the aggregate benefit," Hollenbeck
However, one of the challenges of taking a more conservative approach,
according to Lu-Yao, is that there are no standards for how often to check men
to make sure their cancer hasn't grown, or on when to intervene. And it's not
always clear which patients are the best candidates for watchful waiting or
active surveillance, she said.
"We understand we are doing a lot of over treatment, but we don't really know
which patients are being over treated," said Lu-Yao, who wasn't involved in the
"It can also be hard to tell which men have a limited life expectancy because
of other diseases, and which ones can expect to live long enough to possibly
benefit from treatment," Hollenbeck added.
"Patients that are older and have low-risk disease or have a lot of other
health problems, should really have a frank discussion with their physician about
the perceived benefits of treating their cancer," he said.