more_vert
MEN diagnosed with prostate cancer in the private health system are more than twice as likely to have radical treatment as men diagnosed in the public system, new MJA research shows.
A retrospective analysis of Victorian Cancer Registry data linked to administrative health datasets considered the treatment provided to almost 30 000 men diagnosed with prostate cancer during 2011–2017.
After adjusting for age, tumour classification and comorbidities, the researchers found that the proportion of private patients who underwent radical prostatectomy (44%) was larger than that for public patients (28%), with an odds ratio of 2.28.
They also found that a smaller proportion of private patients (9%) received curative external beam radiation therapy alone (excluding brachytherapy) compared with public patients (19%).
The researchers reported that the magnitude of the difference for prostatectomy was greater for men aged 70 years or more; while for radiation therapy alone, it was larger for those diagnosed before age 70.
Speaking in an exclusive InSight+ podcast, Adjunct Clinical Associate Professor Ian Haines, co-author of the research, said it was a surprising finding.
“Australia has a unique health system with the private versus the public, often served by the same doctors,” Associate Professor Haines said. “I wouldn’t have been surprised if there was a small difference, but I was surprised at the magnitude of the difference.”
Associate Professor Haines said prostate cancer was the most commonly diagnosed cancer in Australia, and studies had shown a high rate of overdiagnosis.
“One recent Australian study that was in the MJA estimated that the overdiagnosis of prostate cancer was about 40% of all the diagnoses,” said Associate Professor Haines, who is a medical oncologist at Cabrini Health and Adjunct Clinical Associate Professor of Medicine at Monash University.
Associate Professor Haines said further research was needed to better understand the reasons behind these difficult treatment decisions.
“It’s a very complex process [for the patient], you don’t want to die, you don’t want to be in pain, but you don’t want the complex treatments,” he said. “The treatment has complications, it can affect potency, can give you diarrhoea if you have radiation therapy, it can cause incontinence of urine, so these are substantial side effects that can affect the quality of life of a lot of men, so there is a lot of discussion that has to be had until you decide on a treatment.”
Associate Professor Haines said further research was needed to better understand the drivers behind these different treatment approaches, but there were several possible explanations.
He said the one-on-one relationship between clinician and patient in private practice, as opposed to attendance at a public clinic, may be one factor.
“And why would men be more likely to have surgery than radiation, for example? Well, it may be that radiation is a long process, you have to turn up daily for weeks, versus one episode of surgery,” he said, adding that patients may decide to “take a chance” on the potential side effects so they can get on with their lives.
Professor Declan Murphy, Consultant Urologist, Director of Genitourinary Oncology, and Director of Robotic Surgery at the Peter MacCallum Cancer Centre, said these findings reflected earlier research, of which he was a co-author, that showed a significant difference in the provision of radical prostatectomy in the private (50.2%) versus the public (28.7%) sectors.
“One of the reasons for this finding, and as we had already reported in our analysis of Prostate Cancer Outcome Registry (Victoria [PCOR‐Vic] data), is that sometimes patients in the public system or in the regions can present a little later. They may present with metastases a bit more often, and hence may be less likely to undergo surgery,” said Professor Murphy, who works equally across the public and private systems.
“So, one of the explanations is quite simply that there are differences between the type of cancer that patients can present with in the public system and can present with in the private system, and the current paper is not able to assess those differences.”
A second reason for the marked difference in treatments provided, Professor Murphy said, was the relative lack of availability of robotic surgery in the public sector.
Professor Murphy pointed to research that his group has in preparation based on national data which shows that, in 2019, 88% of prostatectomies performed in the private sector were performed using a robotic approach, compared to only 28% in the public sector.
While he said patients with prostate cancer attending the public Peter MacCallum Cancer Centre had had free access to robotic surgery for more than a decade, there was still “disappointingly” little access to such technology across the broader public health system.
“There are huge inequities in access to minimally invasive surgery like robot surgery in the private and in the public system and this may also be influencing those utilisation rates,” he said.
Professor Murphy said while surgical experience had a greater influence on patient outcome than the type of surgery, there were distinct advantages to robotic surgery when treating prostate cancer.
“With robot surgery you are going to go home much faster, with faster return to work and less blood transfusions etc, so there are advantages.”
Professor Roger Milne, Head of Cancer Epidemiology at the Cancer Council Victoria and co-author of the current MJA study, said the findings revealed an issue of equity in prostate cancer treatment.
“There are some limitations to this study. We didn’t have measures of [prostate‐specific antigen] or other clinical measures that might be used to determine the intervention, but I think we had sufficient information to conclude that there is something more going on that means the treatment is different in the public and private sector,” he said in the InSight+ podcast. “And getting to the bottom of that would surely improve outcomes for men in terms of getting the optimal treatment regardless of which sector they have been diagnosed in.”
In the meantime, Professor Milne said the Optimal Care Pathways website provided detailed information for clinicians and patients to help to deal with issues of equity along the pathway of care.
Loading ...
In response to the comment PF made about follow-up treatment for recurrence, while what he says about surgery is correct, follow-up radiotherapy can also be undertaken for recurrence after radioRx, as well as several excellent drugs now showing significant benefit..
However, one point I omitted in my first missive – yeah, sorry, it was a bit long – was that I declined taking androgen suppression treatment. Yes, I know it is still recommended as the gold standard, but there are second thoughts about that now, many suggesting it should be retained for salvage treatment in the case of recurrence.
However, with my interest in anti-aging medicine, I just knew it would be very detrimental to my continuing to work as a GP, as not only having no sex hormone does speed up all ageing processes, I doubt patients would want to attend a GP who was tired, showing some cognitive decline and depression, and gaining weight rapidly, all of which are recognised side effects. It also might well have given me hypertension, and for sure would have tipped me from mild glucose intolerance into frank T2D. As it was, I felt great the whole way through the treatment program, and since. My treating specialists urged me to take it, but respected my wish not to, something the average punter would not have felt empowered to decline. Which is why I made it my business to make sure my other men having treatment were aware they could decline it, and why, but did not pressure them in any way to do so. However, I noticed those that did maintained higher spirits through their treatments compared to those who didn’t. Just sayin’…
Pete
There are well documented pros and cons of surgery vs radiotherapy. After 2 years of active surveillance my prostatic cancer, which was initially diagnosed as Gleason 6 after biopsy, showed signs of progression on annual MRI. I chose to have a robotic prostatectomy, and the subsequent histology showed Gleason 7 so I am glad action was taken. One of the reasons that I elected for surgery over radiotherapy (not mentioned elsewhere in the article or comments) is the point raised by my urologist that if the cancer recurred any time after surgery, radiotherapy could still be undertaken with curative intent, whereas after radiotherapy it is very difficult to do secondary surgery on a zapped gland. I am only 60 so it is reassuring to know that I have a second chance to cure the monster if it returns in subsequent years/decades, although 6 weeks post surgery the PSA is only 0.01. Others will have compelling reasons to choose radiotherapy. Possibly the public/private discrepancy has a lot to do with patient characteristics, and just knowing the numbers themselves does not necessarily tell us very much at all.
Having read all comments so far, and also, like some other posters, having been ‘cured’ of ca prostate, I would offer this. I am not surprised at the quoted figures at all. Being a recently retired GP, and because one’s ‘regulars’ tend to age with you, I not only diagnosed quite a high number of men with the condition, and was able to follow their progress and outcomes very closely, but also diagnosed it in myself, when my PSAs rose, and I paid for my own mpMRI, which confirmed a Gleason 7 tumour in two places.
I referred myself to my favourite urologist, (our family GP had just retired, so I was between GPs, as it were), who was very understanding of my desires and obliging, but also made sure I consulted a radiation oncologist. This to me was the crucial thing, and it is beholden on GPs to make that referral, and not just rely on the urologist doing so. Not to put too fine a point on it, and with all due respect, although it is not quite the scenario of the workman who only has a hammer wanting to make all problems a nail, it is a bit unrealistic to expect urologists to forgo the higher financial return of surgery, by not operating, and referring a patient on for radiotherapy, no matter how principled they may be. There is a conflict of interest there at present, hence the figures quoted being no real surprise, especially in the private arena.
After due consideration, I, like others have said, dispensed with the notion of no action, as even though I was 69/70, and the urologist told me it would probably take ten years to kill me, I did not want to live what time in retirement I had with a ticking time-bomb under me – literally.
So, taking note of how I had seen things work out for not only my own patients, but also the studies showing quite clearly those men who chose radiotherapy tended to be happier with their outcomes, than those who had surgery, and as PET CT was neg for mets., I went for stereotactic enhanced, (hence shorter course of higher than usual), EBR.
However, and here is where we keep our urologists on side, I also had my biopsies done trans-perineal, (minimises sepsis issue – I had a friend die of post TRUSS sepsis), and later, before the EBR, the insertion, (also trans-perineal) of a Space/OAR = spacer for organs at risk. A combination injection that in situ and mixed, forms a barrier/wedge that pushes the rectal wall further away from the target area, minimising procto-rectal radiation side effects.
That required two GAs, where possibly, in the future with even better imaging and experience, one might suffice – see later comment.**
Outcome, PSA went from 20 (yep, I sat on it for a bit), progressively done to virtually zero now 3 years later. I was able to continue working as a busy GP throughout, missed no surgery days at all, nearly all sessions being in the evening, (yes, via public), had minimal side effects, other than some bladder irritation after the second large EBR dose, which settled quite quickly. Cranberry extract taken daily for mild urethral irritation cleared that in 6 months, and erectile function was unaltered, apart from needing a bit of the magic pill, which was the case before treatment. My stream is great, and I had minimal procto-rectal side effects other than a bit of mucus after stool for about a year. When I compare how my time since treatment has gone, and the effects on my functions, there is no doubt it my mind that the alternatives to radical surgery must be always considered. Let’s face it, no matter how nerve-sparingly it is done, it always results in significant erectile, and some urinary leakage issues.
So, what’s my point..? Simply that we GPs must make sure patients are offered special advice re ALL the options, including not only surgery, but radiotherapy – now available in several guises and with side effect reduction measures as mentioned – and even focal trans-rectal U/S is also becoming more an option I gather. We should select the most appropriate specialists, and not just assume the urologists do this. This should be based on the most accurate picture one has of the diagnosis and likely stage, before treatment decisions are made, or preferably even before urology referral. I’m still slightly concerned that poking holes in the otherwise quite tough capsule, even to biopsy, might let the ‘cat out of the bag’ if it is sufficiently dysplastic, and with better imaging one might be able to do an accurate minimal biopsy,** (or even no biopsy)** to confirm stage beyond doubt, and Space/OAR insertion, at the same trans-perineal procedure, if EBR was probably the best way to go, and desired by an informed patient. It is also why I was so livid, when we finally got a Medicare item for mpMRI, only to have it restricted to being ordered by folk other than us GPs, so we who are the ones who are following these men, doing their PSas etc, and regularly reviewing them, but also know them personally, are denied that extra tool in trying to best advise our patients, and organise the most preferred referrals. I just hope this short-sighter restriction is lifted before too long. In the end, it will not save money anyway.
Take care and stay safe dear people, sorry about the length, but it’s an important subject, as the numbers show.
Pete
I totally agree with Ray T and Anon. For how many other treatable medical conditions do we offer NO treatment? I am CA free 16 years after open radical prostatectomy.
I have two close friends who have died of prostate cancer. One a physician who took the old “you will die of something else” attitude and confided on his deathbed that he took the wrong advice. The other without private insurance was only offered DXR therapy, six years later he had a recurrence and four years later it gave him a painful death. When my PSA (which I had been monitoring along with my lipids since I was 45) increased (still in the normal range) I shot off and had an MRI, a one punch transperitoneal biopsy confirmed the MRI image of an area of probable Gleason 7. A month later I had my robotic prostatectomy, one night in hospital back at the clinic in a week. I have a little stress incontinence, and most of us in our 70s need Viagra whether we have a prostate or not, small price to pay just to know that I no longer have a prostate.
There is a relevant comment by Sharma, V, et al., Much ado about robotic versus open radical prostatectomy. Lancet Oncology. 2018; 19: 1003-1004. I have summarised it below.
Differences in outcomes from the different operative approaches are probably less important than differences in outcomes from different surgeons. The gold standard for prostate cancer surgery remains a high quality radical prostatectomy, regardless of the approach.
The debate between open and robotic prostatectomy has become less relevant in most economically developed countries, in which more than 85% of prostatectomies are done robotically. Market forces of hospital and provider competition probably drove much of this adoption n the absence of a concrete benefit and despite higher 90-day costs of robot-assisted laparoscopic prostatectomy.
It is crucial to consider the substantial investment necessary to sustain a robotic arms race. Should such investment be diverted to other pursuits with a more substantial, reproducible benefit to the given population? Is improvement in surgical training and skills assessment a more cost-effective means to an end?
Medical professionals should be encouraged to clearly define the benefit of novel technologies before promoting their widespread adoption.
A pensioner friend diagnosed with prostate cancer wanted radical prostatectomy. He was told that it was not available in the public sector. He reluctantly underwent radiotherapy unfortunately with 2 years of every possible complication.
So one obvious reason for these ‘surprising’ findings is that there is a choice of treatments for the privately insured and a lack of choice for public patients.
Back in 2010 at age 66 a biopsy confirmed I had Prostate CA. My private Urologist stressed conservative treatment as a a primary option, outlining the low likelihood of any further problems over the next 10 or 15 years with that approach. Given that I had a familial background suggesting I could live another 30 years in good health, and that I had in the past worked in a Urology unit, I said this was the case and that I preferred a Radical Prostatectomy. He said, “I’m glad you said that – it is what I would do in your place.” I am still in good health, and looking forward to my likely long life. Sure, I have mild urinary leakage and erection issues, but living without uncertainty, and avoiding a slow painful death, is what matters to me. I am still practising part time in my medical specialty.
Planned non treatment is a ridiculous approach.