“Overtreatment is a cause of preventable harm and waste in healthcare.” This statement opens a published study[i] of physician perspectives on overtreatment. The article is based on a survey of 2,106 doctors. The study authors reported the MDs’ opinions as follows:
- 6% of overall medical care is unnecessary
- 0% of prescription medications are unnecessary
- 1% of procedures are unnecessary.
The docs also expressed that overtreatment occurs due to fear of malpractice lawsuits (84.7%), patient pressure or request (59.0%), and difficulty accessing medical records (38.2%).
Overtreatment of prostate cancer
When it comes to prostate cancer (PCa) the standard treatment has long been surgical removal of the entire gland, or radical prostatectomy (RP). Now there’s a growing recognition that when it comes to insignificant PCa (iPCa), this take-no-prisoners surgery is overtreatment. It has been compared to going after a mouse with an elephant gun. Thankfully, today we have a) early and more accurate detection and diagnosis of iPCa; b) knowledge that iPCa tends to be non-aggressive and therefore potentially non-life threatening; c) focal therapies such as our own Focal Laser Ablation have rates of cancer control comparable to RP yet with minimal-to-no risk of urinary or sexual side effects; d) wider use of Active Surveillance for the right patients; and e) more scrutiny over delivery of cost-effective quality of care.
Actual numbers tell us that this increase in awareness is changing clinical practice. A research team out of UCLA’s David Geffen School of Medicine took a good look at their own case files from January 2009 to December 2016. They found 1,283 case files that of RP patients with known clinical factors before surgery, and detailed pathology analysis of the prostate specimens after surgery. From this they were able to determine which patients were found to have iPCa after surgery. They defined iPCa as “a tumor with a Gleason score no higher than 6 and a tumor diameter of 10 mm or less as a surrogate for tumor volume less than 0.5 cc.”[ii] Using that definition, the team found that over the study period, the rate of overtreatment declined by 12% annually, dropping from 15% in 2009 to a mere 3% in 2016.
Speaking for their own center, they attributed this decrease to three main factors, possibly interconnected: lower rate of overdiagnosis (or, stated another way, higher rate of accurate diagnosis before surgery), better patient selection for surgery, and changes in referral patterns. In fact, the authors believe that overtreatment by RP will continue to diminish. It is reassuring to think that the era of an aggressive cookie-cutter approach to treating iPCa is ending, as this study demonstrates.
Shifting winds of criticism
The pioneers in focal therapies such as cryotherapy (freezing)—both interventional radiologists and urologists—were often lambasted by their peers and scorned as irresponsible. After all, everyone KNEW that prostate cancer is a multifocal disease, right? If so, the majority of practitioners held that focal treatment was the same as leaving active cancer behind.
Now, given the insight into RP as overtreatment of disease that might never pose a threat to life, we know that untold thousands of men were needlessly left incontinent or impotent. Outspoken critics like urologist Bert Vorstman, MD have turned the tables, implying that the overuse of robotic RP for Gleason 3+3 prostate cancer is irresponsible, possibly even unethical.
“First, do no harm”
At the Sperling Prostate Center, we offer unique and powerful ways to honor the Hippocratic Oath that all new doctors swear. This includes the principle of “First, do no harm.” For example, before rushing to an invasive needle biopsy, we use noninvasive multiparametric MRI (mpMRI) for high-resolution evidence of prostate cancer. This avoids the risks of conventional TRUS biopsy. If we detect a suspicious area – also called a region of interest or ROI – we provide a real-time mpMRI-guided targeted biopsy which uses minimal needles yet affords the greatest diagnostic accuracy. If a patient qualifies for Active Surveillance, we support that with regular monitoring using biomarkers and mpMRI. Or, if a patient qualifies for focal therapy, we are the leading center in MRI-guided Focal Laser Ablation (FLA). Every day we spare men from unnecessary harm through overdiagnosis and overtreatment!
In today’s world of prostate cancer, there is a role for radical prostatectomy for the right patient. But with the ever-increasing ability to identify candidates for focal treatment or Active Surveillance, we can rightly expect a decline in overtreatment, especially by RP.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you have health concerns or questions of a personal medical nature.
[i] Lyu H, Xu T, Brotman D, Mayer-Blackwell B et al. Overtreatment in the United States. PLoS One. 2017 Sep 6;12(9):e0181970.
[ii] Charnow, Jody. “Decline in Surgical Overtreatment of Prostate Cancer Reported.” Renal & Urology News, Aug. 20, 2018. https://www.renalandurologynews.com/prostate-cancer/surgical-overtreatment-of-prostate-cancer-in-decline-study-finds/article/789583/