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Tuesday, May 22, 2012

Medical Surgeries - Necessary and Unnecessary: Prostate Testing etc.

Surgeon Dr. Nancy Snyderman of NBC is on the news shows talking about the recent ruling against routine prostate cancer screening testing called "PSA".  Her report raises the opportunity to discuss the use of surgical intervention when outcomes may not indicate this is the preferred treatment.

In "What's the Right Choice for You?", Dr. Snyderman writes:  "Prostate cancer is, after all, the second-leading cause of cancer among American males (after lung cancer). More than 232,000 men were diagnosed with prostate cancer this year. And though numbers are dropping, nearly 28,000 will die from it."

Prostate cancer is aggressive when diagnosed in a young man, but almost all aging men will develop anomalies in their prostate. For many aging men diagnosed with prostate cancer, the progression of the disease is so slow that the likelihood of mortality is higher with other age related chronic illnesses. For example, a 70 year old man diagnosed with prostate cancer will likely live his life expectancy and die from some other age related illness.

But the larger issue relates to the necessary and the unnecessary needs for surgical interventions - not only for a potential false positive in a PSA for prostate cancer, but for other conditions as well.

When I worked for medical research projects where small area variation analysis (SMV*) were presented to physicians by the Maine Medical Assessment Foundation, the outcomes for back surgeries was an area of educational focus.

In the research, the same patient satisfaction surveys were given to people who had back surgery for pain and to those who did not choose the surgical option. At first, the two populations reported different outcomes - those who chose surgery said they felt relief from pain while those who sought other treatment reported continued symptoms.  Nonetheless, at the five year post diagnosis survey, both groups reported the same outcomes.  In other words, the people who chose back surgery for pain did not improve in their functional analysis any more than those who made the alternate choice to accept other forms of treatment, like physician therapy or chiropractic treatment.

In prostate surgery, a similar analysis can be researched.  Men who chose prostate surgery may, or may not, have lived for 20 years beyond the diagnosis.  At the time when I worked with SAV analysis, the life expectancy between both the surgical and non-surgical groups of men diagnosed with prostate cancer at about age 70 was nearly the same.

When it comes to mortality from prostate cancer, a candidate for surgery must always evaluate the risks of the intervention versus no treatment at all.  Complications from prostate cancer surgery may be worse than the disease.  Likewise, with any surgery.  Risk of infection and medical error may be greater than living with the symptoms related to back pain or prostate disease.

Although prostate surgery draws the attention of viewers on talk shows, the underlying issue is the over use of surgery and the expenses related to misuse.  When thinking about mortality related to any cancer diagnosis, the fact is, the treatments are expensive related to outcome.  Some cancers respond well to pharmaceutical and other interventions without the need for radical surgeries beyond removal of the primary tumor.

Surgery expenses are not limited to the cost of the medical care and evaluating whether it's needed.  It's more about the expenses related to the risks of having surgery when the alternative may be just as effective and less invasive.

Dr. Snyderman has a succinct communication style where she gets to the conclusion of a medical report very quickly. Sometimes, I find her opinions on medical matters to be loaded with a surgeons point of view - so I assume she is excellent in her physician practice.  In her health column she writes, "If your (prostate) tumor is slow-growing—and the vast majority of prostate tumors are—then there's no immediate health risk. The recommended course of action would be to simply monitor the tumor's growth. Regular PSA testing is an effective way to do that."

Other times, however, Dr. Snyderman misses opportunities to explain risks and benefits of medical research findings.  

In the case of options for prostate cancer treatment, her reports would be more effective if she presented the life expectancy and the patient satisfaction survey outcomes of both the surgical and non-surgical options.

*Small area variation analysis is a research tool used by health services researchers to describe how rates of health care use and events vary over well-defined geographic areas. Significant variation has been shown to exist in the rates of hospitalization for chronic obstructive lung disease, pneumonia, hypertension, and in surgical procedures, such as hysterectomy, cholecystectomy, and tonsillectomy. Potential sources of variation include differences in underlying morbidity, access to care, physician judgment, quality of care delivered, patient demand for services, and random variation. Small area variation studies have been used to determine if significant variation exists across geographic areas and to describe relationships between the observed variation and potential causal factors. Methodologic concerns include the definition of small areas, defining the at-risk population within each small area, sample size, case mix adjustments, and stability of rates over time. The use of small area analysis in primary care will require definition of appropriate small areas for ambulatory care, description of the variation in ambulatory events across small areas, development of appropriate measures for ambulatory case mix, and development of appropriate tools to measure the outcomes of ambulatory care.



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