New Consumer Advice on Prostate Cancer Includes 'Value'

Zosia Chustecka

February 15, 2016

Being confronted by a spectrum of potential treatments can be bewildering, so a new initiative, called Proven Best Choices™, has been launched to guide patients through the maze.

These documents offer — for the first time — information to patients on the "relative value of treatment," notes Caitlin Morris, from Families USA, a nonprofit healthcare advocacy group that has produced the guides in partnership with the Institute for Clinical and Economic Research (ICER), a nonprofit organization that evaluates the evidence on the value of medical tests, treatments, and delivery system innovations.

One of the first of these guides, released last month, is aimed at men with low-risk prostate cancer, and Medscape Medical News approached three experts to comment on it.

"I applaud these efforts to provide guidance to patients regarding treatment options for low-risk prostate cancer, and for taking cost into consideration," said Stacy Loeb, MD, assistant professor of urology and population health at New York University in New York City. But she pointed out that the document missed a very important point that needs to be considered — the patient's life expectancy.

Another expert was not impressed. Marc B. Garnick MD, Gorman Brothers Clinical Professor of Medicine at Harvard Medical School and the Beth Israel Deaconess Medical Center in Boston, and editor in chief of the HMS Annual Report on Prostate Diseases, said the guide is "overly simplified."

This is one of the "most controversial areas of clinical medicine and urologic oncology — that of providing concise advice to come to the aid of the bewildered patient when selecting therapies for low-risk prostate cancer," he commented to Medscape Medical News. Overall, the guide "does little to advance the complexities of decision-making for our patients," he said.

Dr Garnick is concerned that "the advice is misleading and sanitized; there is no place for nuances related to a patient's specific circumstances."

And he objected to the use of the word "proven" in the trademarked name for these guides, saying it is misleading. "I only wish that we did have 'proven' choices for this disease which is so complicated and in need of significantly more research to get to the true 'proof', he told Medscape Medical News.

Guide to Low-risk Prostate Cancer

The new document on low-risk prostate cancer says there are three "best proven choices" — active surveillance, surgery, and brachytherapy, which involves the insertion of radioactive seeds into the prostate.

The guide then lists intensity-modulated radiation therapy (IMRT) and proton-beam therapy as "lower value options."

There are large cost differences between these three types of radiotherapy, Dan Ollendorf, PhD, chief scientific officer at ICER, explained to Medscape Medical News.

Typical costs are around $10,000 to 15,000 for brachytherapy, $25,000 to $30,000 for IMRT, and more than $50,000 for proton-beam therapy. In addition, the brachytherapy involves a single visit during which the radioactive seeds are inserted, whereas the other two involve a series of visits for a course of radiotherapy.

However, he also noted that brachytherapy is not widely used, and that its use varies geographically across the United States.

IMRT has been, in the past, the second most commonly used treatment option, after surgery, which has been the most common, accounting for about 60%, he said. But there have been changes in management in recent years, and registry data published last year (JAMA. 2015;314:80-82) show that active surveillance increased sharply from 2010 to 2013, and now accounts for about 40%. Surgery still accounts for about 50%, and the remaining 10% is made up of radiotherapy.

Dr Garnick said that guide does a disservice by placing IMRT in the unfavorable position of a lower value option, which he said is a "truly arbitrary designation." In addition, he said that the information on brachytherapy "is devoid of any discussion regarding side effects, which in this case can be debilitating and cumulative over years."

Another expert also questioned the comments on radiotherapy. David Penson, MD, MPH, professor of both urologic oncology and urologic surgery at the Vanderbilt University Medical Center in Nashville, Tennessee, said that, overall, the guide is "reasonable and accurate," but added: "That being said, in certain patients, external-beam radiation (IMRT or proton beam) may still be of high value. I wouldn't completely dismiss those treatments in low-risk patients."

"Simply put, different patients are going to have different preferences, such that the value may vary from patient to patient," Dr Penson told Medscape Medical News. "That being said, these recommendations make sense on a population level."

Active Surveillance Option

Dr Garnick said that the guide had many inaccuracies, including one in the active surveillance section, which indicates that this involves undergoing a prostate biopsy every year. "While this may be true for the first year, most active-surveillance programs call for biopsies every two to three years," he said, and "there is no mention of the emerging and important studies of genomic testing to help drive decision making."

Dr Loeb, in her reaction, also homed in on the same point of biopsies every year, pointing out that some programs space the biopsies at longer intervals, and also that many active-surveillance programs are also beginning to integrate newer tests, such as multiparametric MRI to help guide the biopsies.

But she said she is very pleased to see this option highlighted: "I agree wholeheartedly that the option of active surveillance should be considered by all men with low-risk prostate cancer."

Countering these comments, Dr Ollendorf said that the section on active surveillance sets out "the most conservative approach" that the patient may expect, and he agrees that the frequency of biopsies varies, for example from one institution to another, and also depends on specific individual circumstances. He also said that the data on genomic tests so far are preliminary, and these tests are not proven.

Dr Loeb also pointed out that the guide does not mention at all the patients' life expectancy, which is a "a very important factor in treatment selection for low-risk prostate cancer."

She cited guidelines from the National Comprehensive Cancer Network (NCCN), which state that for men with a life expectancy of less than 10 years, observation is the preferred management for low-risk prostate cancer. For men with a life expectancy of 10 to 20 years, active surveillance is the preferred management. It is only for men with a life expectancy of 20 years or more that the NCCN lists the choices as including active surveillance, radical prostatectomy, and radiation therapy (brachytherapy or external-beam therapy), which is broadly similar to the choices outlined in the new document from FamiliesUSA/ICER, except for the fact that it adds on the value comment on the different types of radiation.

Further Guides Under Preparation

The initial batch of these Best Proven Choice guides was produced with seed funding from the Kaiser Permanente National Community Benefit Fund at the East Bay Community Foundation. In addition to the document on prostate cancer, another one covering women with dense breast tissue was released in January, and three others are under preparation, covering attention deficit hyperactivity disorder, lower back pain, and asthma.

These new guides offer information and discuss clinical effectiveness and cost-effectiveness, and this discussion of value is new, noted Morris, from Families USA.

In the United States, insurers are increasing the amount of patient share of costs of treatment, either as copayment per visit or as a coinsurance for a percentage of care, and some insurance schemes are even leaving patients to pick up all the bill for their treatment, Morris explained in an interview.

"This info is long overdue," said Dr Ollendorf. Patients are having to become more financially responsible for some aspects of their treatment, and it is important for them to be informed about the costs involved in various treatment options, he said in an interview.

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