Readers, due to some, er, technical issues on Dr. Len’s blog (it just won’t work), we welcomed his post here. Enjoy! –djs
By: Len Lichtenfeld, MD, Deputy Chief Medical Officer, American Cancer Society
“Up, Up and Away” were the words of a song popular many years ago, but today may best reflect the incessant rise in the costs of medical care. And the reality is that the balloon may have been a nice ride, but we can’t say today that we know whether or not we are getting our money’s worth when it comes to certain treatments, such as those now being popularized for the treatment of prostate cancer.
That’s the message from a paper published on-line this week in the Journal of Clinical Oncology which looks closely at the substantial increase in the costs of treating men for prostate cancer, which is by far the most common cancer diagnosed in men in this country today.
The researchers examined the costs of treating about 71,000 men for prostate cancer in the fee-for-service Medicare program from 2002 through 2005, with follow-up through the end of 2007. The costs of treating men with surgery or radiation was the focus of the research and included a comparison of men who received external beam radiation, seed-implants (also known as brachytherapy), a combination of these two treatments, “open” nerve sparing surgery for prostate cancer, or “minimally invasive radical prostatectomy” (MIRP) which could have been done with a laparoscope, but more likely with the new robot surgery.
Then, the researchers compared the costs in the Medicare program for whatever treatments the men received for the year before they were diagnosed with prostate cancer and compared that to the costs of treating the same men for a year after their diagnosis. In the study, 11,894 men had received surgery, 17,274 men had only external radiation, and 16,468 had seed implants with or without additional external radiation.
What the authors found was that there was a rapid increase in the use of the more expensive forms of treatment over the period of the study.
For example, in 2002, of the men who were diagnosed with prostate cancer and had surgical treatment, 1.5 % had MIRP, while in 2005 the number increased to 28.7%. IMRT-an advanced and more expensive form of radiation therapy–was used by 28.7% of the men treated with radiation in 2002, and 81.7% in 2005.
The costs of this Cadillac treatment? Here is what the authors had to say: “Compared to the less costly alternative, the nationwide excess direct spending for the rapid adoption of more expensive therapies was $282 million for IMRT, $59 million for brachytherapy plus IMRT, and $4 million for MIRP for men diagnosed in 2005.” My calculator tells me that is $345,000,000. That, my friends, is not chump change.
So what do we get for that money? Do we get better outcomes? Do we get better medical care? Do we get fewer side-effects of treatment? The answer, surprisingly, is, “Who knows?” A more relevant question may be, “Does anyone care?”
You see, as the authors point out very clearly, no one has ever done a head-to-head study to find out whether or not one treatment is better than another. This appears to be a case of, “If you dream it, and you build it, they will come-costs be darned.” No need to prove benefit, no need to prove that one treatment is better than another, no nothing. Just a big advertising budget will do along with some good press and word of mouth.
What’s even more disconcerting about this study is that it reflects Medicare spending-which is substantially less for procedures than generally paid by private insurers. And, to further confuse the situation, the true increased costs of the new robot surgery are not reflected in the cost data because of the quirks of the Medicare program. So the estimate of $4 million dollars probably substantially underestimates the true increased cost of robotic surgery, since as the authors note the machines cost $1.4 million, annual maintenance is $140,000 and each procedure costs a good hunk of change for the disposable equipment used in each surgery (think of the “inkjet” strategy for your computer printer: the printer is reasonably inexpensive, but replacing those expensive ink cartridges is a regular, life-long event).
The authors acknowledge that for the more advanced forms of radiation there are studies which suggest some benefit. For the robot on the other hand, the reviews are mixed. And that doesn’t include the information from a recent study that found it took several experienced prostate cancer surgeons 1600 cases until they became maximally effective at removing as much of the prostate as possible with robotic surgery.
They go on to write: “However, even if there is some underlying clinical benefit to these newer, more expensive therapies, it is still important to ask whether the marginal benefit of these therapies is large enough to justify their higher cost.” And, it doesn’t stop here.
At the annual conference of the National Comprehensive Cancer Network-a coalition of a number of the country’s leading cancer centers-an expert in radiation therapy told a session about a proton beam radiation center being built somewhere on the East coast. That center will cost $350,000,000 according to the expert, and he stated publicly he found little to support that kind of investment. In fact, he noted, the major claim of benefit from proton beam therapy was a reduction in side effects related to radiation of normal tissue. However, he went on to say, if that’s the case then seed implants accomplish much the same goal at significantly lower cost.
More important, he asked from the stage, who is going to pay for that treatment? And who is going to receive all that proton beam radiation, when the generally accepted and demonstrated indications for such treatment are much more narrowly defined, such as in certain pediatric and skull-based cancers? I don’t think you have to be a rocket scientist to figure out who is going to pay for that technology, and I can already see the men lined up to get their prostates irradiated with the newest, best and most-hyped gadget available-regardless whether or not it really makes a difference.
I have seen how this works first hand with the robot. First one hospital gets it, advertises it, builds its surgical volume and proclaims widely through billboards, web ads and so on that they are “robotic specialists.” Patients want the robot because they assume it is the best thing available and it sounds great. Then another hospital says they need a robot, because their surgeons want it and because they are losing cases to the other hospital that has the robot. And this goes on and on, until patients detour from their local doc to the place that has the robot. And then even the small hospitals need to have it because their patients are going miles down the road to get the robot.
Guess what? Frequently it is the skill of the surgeon-not the robot-that makes the difference. There are no really good studies that show Mr. Robot makes a difference-except in the pocketbook, either yours or the insurers. The legend lives on to grow greater every day. So let’s get back to the balloon song that opened the blog.
Maybe the most appropriate way to view this is not a balloon, but a bubble. This bubble is going to grow and grow and grow, and then-like all good bubbles-it will inevitably burst. We need to provide the best medical care we can to those who need it when they need it. We need to know what works, what doesn’t work, what is real and what is hype.
This particular report says to us-once again-that we are a long, long way from figuring out the answers to those questions. Until we do, it is going to continue to be “Up, Up and Away…”
As I was writing this post, I read about a very relevant and excellent opinion piece that appeared on Bloomberg. Hat tip to Gary Schwitzer for pointing it out.