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Rise in high-end treatment for low-risk prostate cancer

By Genevra Pittman

NEW YORK (Reuters Health) - The proportion of U.S. 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 (see Reuters Health story of June 17, 2013 here: http://reut.rs/12EX8fl).

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, she told Reuters Health, "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."

Hollenbeck and his colleagues analyzed 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 percent in 2004 to 44 percent in 2009.

Likewise, the technologies' use among men with other serious health problems increased from 36 percent to 57 percent, Hollenbeck and his colleagues reported on Tuesday 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.

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 told Reuters Health.

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 overtreatment, but we don't really know which patients are being overtreated," said Lu-Yao, who wasn't involved in the new research.

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.

SOURCE: http://bit.ly/JjFzqx Journal of the American Medical Association, online June 25, 2013.

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