“This is another article which highlights the debate over PSA screening for prostate cancer. It seems that although the US Preventative Task Force has decided unilaterally to recommend against PSA screening, government officials including President Obama and Senator Wyden have chosen to ignore the recommendations and have their PSA screened. Senator Wyden additionally underwent surgery after being diagnosed with prostate cancer.” David Robbins
The politics of prostate cancer
Sen. Ron Wyden had surgery for prostate cancer Monday, putting himself — through no fault of his own — in the middle of a debate about diagnosis, treatment and bending the cost curve.
The longtime health care advocate and Oregon Democrat was operated on by Alan Partin at Johns Hopkins Hospital in Baltimore. The cancer was caught early, and Wyden, 61, has an excellent prognosis, according to his office.
The option known as “active surveillance” (formerly “watchful waiting”) allows patients to avoid or delay surgery, radiation and chemotherapy — and the side effects that come with those treatments. Active surveillance means coming back to the doctor on a regular schedule for a blood test and examination to see if the cancer is growing. But few men choose it.
Wargo discusses active surveillance with her patients, and she considers it a good option for those who fear surgery or have other serious health problems. She is on board with the new nomenclature. “Watchful waiting sounds like you can just go disappear and not come back to see me,” she said. But she understands why many men choose surgery. “There is a personality of men who can’t live with the idea that there is something inside them that could kill them.”
Bruce Quinn, M.D., health specialist with Foley Hoag and a former official in California’s Medicare program, pointed out that, over a five-year period, active surveillance doesn’t save significant funds, because the slow-growing cancers often become aggressive and require more expensive, invasive treatment.
“It’s not the difference of $100 versus $30,000 if you look at the cost comparisons over five years. Active surveillance is more costly than people think,” said Quinn. “It’s not popular, I think, because patients must find it pretty uncomfortable to be told they have a 2-to-3-centimeter tumor that could eventually blow up and kill them, and we’re just going to watch it. Men say, ‘Just get the damn thing out!’”
Wargo and Quinn both noted problems with the prostate-specific antigen test that is the screening tool used for diagnosis. A normal level in one individual might be abnormal in another, and doctors need to track changes in the level over time to approach any kind of accuracy.
“You really have to look at each patient individually,” said Wargo. “A PSA level of 4 is normal in an older patient, but it is completely unacceptable in a 47-year-old. You can have a low level and still have aggressive prostate cancer.”
Complicating matters is the fact that no test accurately predicts who will get the aggressive, deadly form of the disease and who will get a slow-growing, non-life-threatening form. Quinn points to Medicare reimbursements as part of the problem.
In choosing surgery over what used to be called “watchful waiting,” Wyden took a path that many men take when faced with a prostate cancer diagnosis. But increasingly, that path is questioned in the era of health care reform, as cost-cutting is pitted against personal choice.
Doctors acknowledge that the cost-cutters have a point but bristle at the intrusion into the physician-patient relationship.
“It is well and good for statisticians to say, ‘This is the patient who doesn’t need to be treated,’” said Heather C. Wargo, a urologist practicing in Mount Laurel, N.J. “But when I am sitting with a patient, looking him and his spouse in the eye, it is very difficult to say, ‘I’ve been accused of overtreating, so I’m not going to treat you.’”
The U.S. Preventive Services Task Force, the body that sparked a firestorm when it said that most women do not need an annual mammogram until age 50, was set to vote on new prostate-cancer-screening recommendations last month. Instead, the panel canceled its November meeting, citing “scheduling conflicts.”
Kenneth Lin, professor and family physician, quit the task force in protest. “Politics trumped science this time, as it has in the past, and may at times in the future,” Lin wrote in his blog, where he linked to a news account of the mammogram controversy.
Rep. Debbie Wasserman Schultz (D-Fla.), who had breast cancer, told POLITICO that the task force “seems out of touch with reality.”
“I think that organization really undermines its credibility, not necessarily among the scientific community but for the general public,” Wasserman Schultz said, noting that there were no cancer experts on the panel when the breast-cancer-screening recommendations were made.
Yet statistical analysis like the task force’s research has some of the greatest potential to save money on health care spending.
Prostate cancer is ripe for study. Researchers question whether it is being overdiagnosed and whether too many surgeries are being performed on tumors that would never become dangerous.
“The Medicare fee schedule is around $20 for the PSA test, and it is just frozen there,” said Quinn. “It’s really hard for companies to do the trials that they need to do to come up with a more effective, more precise prostate cancer test with this artificially very low fee.”
Mara Aspinall is CEO of On-Q-ity, a company working on new diagnostic tests that have the potential to identify rare cancer cells circulating in the bloodstream, long before they are prevalent enough to be picked up as tumors on MRI and CT scans.
Aspinall said the Medicare fee schedule is a problem for her new technology. “In the laboratory, the more steps your process has, the more you’re paid,” she said. “This was a useful construct some time ago, but it has not kept pace with technology. We now can have one really big step to replace 10 small ones. It’s an incredible disincentive.”
While Aspinall argued that better diagnostic tests could bring more clarity and potential cost savings to prostate cancer treatment, she emphasized that tests can’t replace the doctor-patient dialogue.
“It is essential that the decision on how to proceed — even in the era of diagnostics — needs to continue to be an educated discussion between the physician and the patient,” said Aspinall. “We want to bring more information to the equation.”
Wyden will no doubt be helpful in bringing more information to the equation as he recovers from his disease. He started working on public health issues as a young lawyer when he founded a legal aid society for the elderly and Oregon’s first chapter of the Gray Panthers. During health care reform, he was the architect of the Healthy Americans Act, which would have radically changed health care from the employer-based system, and now he is co-sponsoring a bill that encourages states to innovate on reform implementation.
“If anything is taken away from my experience, I hope it is the importance of getting routine physicals,” Wyden said as he was disclosing his disease last week. “One in six men will be diagnosed with prostate cancer during their lifetimes. Early detection is critical to catching this disease when treatment is most effective.”