“There is increased use of radiotherapy among patients with indolent prostate cancer with limited to no correlation with tumor biology.” This conclusion was reached by a research team out of UCLA after studying the treatment choices of 37,621 patients.[i] In fact, over half (57.9%) of the men were sent for radiation, while 19.1% had a prostatectomy and a mere 9.6% went on active surveillance. The fact that radiation was prescribed “with limited to no correlation with tumor biology” is chilling.
Radiation is a radical (whole gland) treatment known for its risks of late onset side effects. Months or even years after their treatment, untold numbers of the patients in this study would have experienced loss of sexual function, pelvic inflammation, urinary or bowel problems, and an increased risk for secondary cancers such as bladder, rectal or colon cancer. This means that annually, thousands of men with low-risk disease are overtreated.
True, a certain percentage of prostate cancer patients may do best with radiation. Those who can’t have surgery (usually due to their age or to co-existing medical conditions) are often referred for radiation. However, patients who are too old for surgery (usually 65 or 70 is considered a cutoff age) are often those who are likely to die “with prostate cancer, not from it,” because they have slow-growing disease. So why treat them at all, when they may be ideal candidates for active surveillance?
Recently, news reports have appeared about urologists who have a financial interest in radiation centers, where they can refer their prostate cancer patients for treatment. For example, an August 2014 Arizona paper told of a radiation clinic owned by “urologists who refer prostate-cancer patients there for an expensive type of radiation therapy collected more from Medicare in 2012 than any other similar provider in Arizona.”[ii] We must ask, whose best interest is being served if low-risk patients are radiated, especially when the treatment center is partly owned by the urologist making the referral?
Even if there’s no financial conflict of interest, it’s about medical ethics. The Hippocratic oath, taken by all doctors, contains the following promise: “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”
Today, there is no excuse for overtreating prostate cancer when we have breakthrough technologies such as multiparametric MRI that can reveal the location, size and shape of a tumor as well as give clues to its aggressiveness; targeted biopsy for accurate diagnosis; genomic analysis for refined information on dangerous cell lines; and focal ablation for qualified patients. If there is any doubt as to whether a man is a candidate for active surveillance, focal ablation, or radical treatment, it is possible to gain a high degree of confidence in a treatment decision because we can know what we’re dealing with. Let’s finally stop overtreating prostate cancer.
[i] Chamie K, Williams S, Hu J. Population-Based Assessment of Determining Treatments for Prostate Cancer. JAMA Oncol. Published online February 19, 2015. doi:10.1001/jamaoncol.2014.192 FREE
[ii] Alltucker, K. Medical ‘self-referral’ practice raises conflict of interest questions. The Republic. Aug. 17, 2014. http://www.azcentral.com/story/money/business/2014/08/17/phoenix-radiation-referral-medicare/14192375/