No, it’s not because greedy providers have devised needlessly expensive treatment modalities, or just been lax in choosing cheaper alternatives among the many modalities in use. The treatment of prostate cancer is in flux right now because we haven’t had time to adjust our treatment strategy to the flood of early prostate diagnoses created by widespread use in this country of PSA screening for prostate cancer.

Before the PSA, we only found prostate cancer when it had advanced so far as to create symptoms that prompted the patient to seek medical attention, or it had grown so large as to produce a nodule palpable on rectal exam. Now, based on observation of how often prostate cancer found by these means, found clinically, advanced how quickly to life or health threatening behavior, we had established a treatment strategy that dictated what characteristics of the newly diagnosed prostate cancer justified what intervention. What we have found with the PSA is that it discovers prostate cancers that are clearly at least somewhat less aggressive in their time course, and arguably are mostly such slow-growers that the patient is more likely to die with them than of them.

The problem is that the only way to get firm answers about the natural, untreated, history of PSA-discovered prostate cancer is to stand back and not treat such cancers in the tens of thousands of patients you would need to observe for years and decades to start getting these answers. And it is highly problematic to stand back and not treat prostate cancer when the form of it that we have observed, clinically-discovered prostate cancer, is a known killer, one of the leading causes of death among men in this country. On a population health level, I can guarantee that we will never be able to do the direct and obvious study to figure this out, since it would be like the Tuskegee syphillis study, just on a much larger scale. But until and unless we do have more firm evidence that PSA-discovered prostate cancer is such that the strategy of watchful waiting is not a death sentence, on the level of the indiuvidual patient, aggressive treatment, as if we were dealing with clinically-discovered prostate cancer, will have to continue, despite the fact that there is a strong likelihood that much of that aggressive treatment might eventually be proven unnecessary. You can’t wait for “eventually” when your patient has the PSA of 16 and needs a decision today.

It gets worse. The only two things we can do to treat prostate cancer are inherently quite aggressive. We can suppress testosterone production, because testosterone encourages prostate cancer growth. But that only slows progression, doesn’t cure, and another name for pharmacologically suppressing testosterone production, the name we use when we’re talking about doing this to sex offenders (by the way, it doesn’t work in this role, and doing this to sex offenders is unmitigated cruel and unusual abuse), is “chemical castration”. Nice. But not as bad as the effects of removing the prostate, the other treatment option available. The prostate itself we can arguably do without, but all sorts of plumbing and wiring either goes through or so close to the prostate, that removal threatens to destroy all sorts of other functionality. Fecal incontinence is not fun.

Most of the specific treatment modalities Leonhardt mentions are alternate ways, other than surgery, to destroy the prostate. They are being tried, despite the expense and uncertain risks associated with novelty, because there is some reason to believe that they will allow more selective destruction of the prostate itself, while sparing other functionality. Such sparing of other functionality has its cost savings, human costs mostly, but even monetary costs, that need to be added into the balance sheet. And if any such modality does prove to do a much better job of sparing funtionality, it will become widely used and bring down the costs dramatically as the new equipment’s cost is spread over more and more patients. When I was in med school, CTs were quite expensive, but they proved very useful, and everybody bought scanners. So now the start up costs have all been paid, and a sinus CT is cheaper than a plain film sinus series. None of these modalities is inherently more expensive than scalpel surgery, they’re just all newer and use equipment that hasn’t been universally adopted — yet.

So, the moral of the story is, early detection is bad? No, not at all. In this case of PSA screening, yes, it was arguably wrong for it to have been pushed as a universal standard before we had any idea of how this should impact treatment, any clear reason to find prostate cancer early. On the individual patient level, given the uncertainty of what it tells us, the fact that what we know of clinically-discovered prostate cancer is all we know of this disease’s natural history, and that is not a reliable guide to the natural history of PSA-discovered prostate cancer, the decision to have such testing is very fraught, because of the invasive nature of the only treatments available for a condition whose prognosis is not known. I have chosen to forego testing myself, and I will not order it for my patients until and unless they pay reasonable attention to counseling about these uncertainties, after which a goodly percentage (though <50%) also choose to not be tested.

Messy as this situation is, though, such messes are the way, the only way, for an observational, inductive, science such as medicine to advance. Eventually, but probably only by fits and starts because the brute force method of determining the natural history of PSA-discovered prostate cancer is not practicable (So, do we randomize YOU to the non-treatment group?), we will know if and when to unleash testosterone suppression and prostate removal on prostate cancer discovered by PSA. Perhaps, more optimistically, this tough spot we’re in right now with prostate cancer, will be the spur that gets us a way to remove the prostate without destroying other functionality.

At any given time, most areas of medicine will be more settled than prostate cancer treatment is right now. This is especially true the more common the problem. And after things settle out, very few people have the severity of disease to justify invasive, and therefore expensive, treatment modalities. The treatment of Coronary Artery Disease (CAD), for example, has pretty much quieted down after its recent disturbance created by the introduction of new treatments (CABG, angioplasty) and new diagnostic means (catheterization, imaged functional testing). Very few people have CAD so threatening of death in the near term that CABG is justified. We’re not going to bankrupt the nation making CABG available to everyone who needs it, because so few need it so badly that the risks and other human costs involved justify using it.

In the long term, we are not going to bankrupt the nation making even the most expensive treatments for prostate cancer, or any disease currently in the sort of flux that this cancer is in, available to all who need such treatment. The inherently expensive treatments, the ones whose cost will not go down after they become widely used, are that way because they are invasive, and because they are invasive, they will never be indicated for very many patients.

What I find concerning about Leonhardt’s item, and its citation here, is what many people find concerning about the proposal to reform health care financing. Some thinkers on the subject advance a wholly unnecessary opposition between cost and quality, and thereby create the fear that universal health care will require economies that will squelch medical advances. It definitely doesn’t need to be so, but insofar as Leonhardt’s thinking prevails in the design of the single payer that this country so desperately needs, there is a real danger that an unnecessary oppostion of cost and quality will be decided pre-emptively in favor of low-bid medicine. But we don’t actually face the need to choose between cost and quality. We simply need to follow enlightened self-interest, and avoid being penny wise and pound foolish, or defining our interests on too short a term, and we can have both high quality and low cost in our medical care. One of the things our reformed system will have to allow is for areas of medicine to get messy, confused and more expensive after new diagnostic or therapeutic modalities are introduced, but before our observation of the consequences can catch up.

…just a beggar lookin’ for a ride…

We have been sold a pile of dung!!!!!!!!!

Another example would be cardiac stenting. This doesn’t increase longevity but it does increase quality of life. We need to discuss what tradeoffs we are willing to make and those we are not willing to make.