Over-Diagnosis and Over-Treatment in the Flourishing Prostate Cancer Business

BY RALPH BLUM

There are several reasons why over-treatment of prostate cancer is rampant in this country. The first is over-diagnosis. In 2011, despite the controversy about annual PSA testing, more than 240,000 men were diagnosed with prostate cancer. Many of these men were in their 70s and 80s; most of them with disease that would never be clinically significant in their lifetimes. But a diagnosis of prostate cancer put them at immediate risk for unnecessary treatment. Why? Because both doctors and patients over-react to the information PSA testing provides.

The responsible urologist is faced with a dilemma: the risk of over-treatment versus the risk of his patient dying from prostate cancer. As of this writing there is still no absolute certainty, when a man is first diagnosed, about how to accurately differentiate between clinically significant and clinically insignificant prostate cancer.

Then there is the financial aspect: prostate cancer treatment and management has become a flourishing industry. Studies have found that three-quarters of men with indolent, slow-growing tumors receive unnecessary aggressive treatment, when active surveillance would be far more appropriate.

According to researcher Janet Stanford at the Fred Hutchinson Cancer Research Center, between $2 and $3 billion is spent annually in the U.S. on initial therapy alone. Urology groups that have brought IMRT into their practices have utilization rates well above national norms for treatment of prostate cancer, and these practices also treat a higher than average number of men over the age of 80 with IMRT for their low-risk cancer. Furthermore, with the soaring popularity of the da Vinci robot and the enormous costs of acquiring one, not to mention being trained in robotic surgery, there is a very strong incentive for urologists to recommend its use.

I’m not suggesting that men are not willing partner’s in this rush to treatment. Most men, confronted with a choice of monitoring their prostate cancer—as opposed to “cutting it out” or zapping it with radiation—will unequivocally choose the latter, even knowing that it is likely to lead to reduced quality of life. One of the results? Over 70,000 unnecessary prostate surgeries annually—and rising.

While PSA screening isn’t a perfect method of detection, catching prostate cancer early has saved many men’s lives. Over the last 30 years there has been a 30% decline in the death rate from prostate cancer due, in part, to better screening. However, all you guys out there who are diagnosed in your 70s or 80s, be aware that the highest incidence of over-treatment is in your age group—as high as 60-65% and possibly higher.  So take your time, and carefully examine your options!

As the prostate cancer wars rage on, all newly diagnosed men are faced with prostate cancer’s version of the Hamlet dilemma (“To be or not to be…”). As Leonard L. Gunderson, M.D, M.S, FASTRO and ASTRO Chairman put it, “The problem with prostate cancer is not finding the cancer but in knowing when to treat and when not to treat.”