NY Times Article...The Future of PCa treatment here?

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Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 7/8/2009 10:25 PM (GMT -6)   
I would bet more that half won't like this discussion.  Social medicine challenges and prostate cancer...
 
 
The article is well written, however.
 
Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


JoeyG
Regular Member


Date Joined Jul 2009
Total Posts : 162
   Posted 7/9/2009 7:54 AM (GMT -6)   
Here's hoping that what comes out of this is both sensible and cost-effective.
 
BTW: Most of those costs on the left hand table look very very low. 
Age -57; Diagnosed 10/05 PSA 13.4 GS 9 Organ confined
Cryoablation 4/06 Allegheny Hosp-Dr Ralph Miller (Cohen/Miller)
Post Cryo Nadir 8/06 0.2
Rising steadily to 0.7 4/09 :-(
Looking to take next steps soon
Hoping to qualify for salvage cryo or radiation


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 7/9/2009 9:06 AM (GMT -6)   
I thought about posting this story, but I feared that it might lead us into a political debate inappropriate to this forum. But since it is here, I will try to make some non political comments.

The part of the article which I found most disturbing was the following:
“Imagine if further prostate research showed that a $50,000 dose of targeted radiation did not extend life but did bring fewer side effects, like diarrhea, than other forms of radiation. Should Medicare spend billions to pay for targeted radiation? Or should it help prostate patients manage their diarrhea and then spend the billions on other kinds of care?”
This is very narrow economic thinking. Since no one pays cash for quality of life it has no value. Clearly “bean counting” is not a sound basis for making all medical decisions.

I have not been able to track down the source of the cost data given for the various treatments (I tried authors’ names in PubMed) but it looks to me that these are “list price.” That is, what is billed rather than what is actually paid. I think that the hospital and surgeon bills for my prostectomy were about $27,000 but were settled by my insurer at well less than half of that.. It is rather like the $800 “Rolex” watch my brother has, he talked the guy on the street down to $15
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0


engineer55
Regular Member


Date Joined May 2009
Total Posts : 121
   Posted 7/9/2009 9:20 AM (GMT -6)   
I think cost benefit studies are a great idea, but the studies have not been  finalled, and writers should watch what they say.  This guy is not too bad but there is a group out there suggesting we drop PSA tests.
 
First off no doctor would rec watchful waiting for a person under 75, but they ALL suggest active surveillance, there is a big difference, including cost.  I estimated my AS prgram with office visits, yearly biopsies, pathology checks and avodart was going to cost $3000/ year, most of it paid by me.  This would be every year until eventually I drop the big one, so I did not see it as overall cheaper.  It wasn't going to make it go away, just delay the final procedure.
 
The other thing, and this is why we need studies, at least from this board  it seems there have been a significant number of guys who had worse than expected after surgery pathology, waiting probably would have killed them or at least driven costs trough the roof.
 
 
Last thing is with the high % of prostrate cancer, even a small percentage improvement equates to thousand of lives saved.
Dx'ed 5/08 one core 2%  out of 12  3+3 gleason
DREs all negative
PSA was in the 3-4 range then jumped to 7
I have the enlarged prostate, on the order of 100cc.  After taking Avodart for 3 months  my
PSA was cut in half.
I did Active S for a year but concluded that I didn't want a life
of biopsies and Uro meetings.
DaVinci on 6/24/09  UCI Med Center  Dr Ahlering, long surgery based on size and location
Final was 5% one side all clear, but had a huge 90 grm prostate
Now we work on pee control, ok at night but sitting is a big problem.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 7/9/2009 9:27 AM (GMT -6)   
Joey,
I agree, the costs are below what we would normally pay, at least for surgery...

Geezer,
I believe what they were saying is that IMRT has no life extending beyond that of surgery or other therapies. So that stated, I would agree. No need for politics to have a point of view. i posted this article because it matters to cancer patients. Prostate cancer was the example. And when a term exists called "least cost alternative" then what decides what we do could end up a financial decision made for treatment as opposed to apreferential one. Many are already faced with that decision,

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


SHU93
Regular Member


Date Joined Aug 2008
Total Posts : 328
   Posted 7/9/2009 9:36 AM (GMT -6)   
I have many issues with the article, but will make two comments. It just shows the need for more Prostate Cancer Research, where it lacks greatly!!! If he compared to other cancer treatments for example Breast Cancer which has options as well? Would the public reaction to this article be the same?
Age Dx 37, 7/2008, First PSA : 4.17 5/2008
Second PSA After 2 weeks of antibiotics : 3.9 6/2008
DRE: Negative 5/2008, Biopsy: 6 out 12 Postive all on right side, Gleason 7 (3+4). Bone Scan/CAT Scan: Clear 7/2008
Cystoscope: Normal 7/2008, Prostate MRI: Normal 7/2008
Da Vinci Surgery 7/2008, PostOp: T2c (On Both sides), margins clear, seminal clear, nodes, clear. Gleason 6(3+3).
4 Post OP PSA's from 9/2008 to 6/2009: <0.1
 
 
 


lifeguyd
Veteran Member


Date Joined Jul 2006
Total Posts : 674
   Posted 7/9/2009 10:18 AM (GMT -6)   

 

Interesting article, We all struggled with treatment choices, usually without enough information.  My doctors all agreed that I had a lethal but isolated cancer that would best be treated with surgery. The bills were high, but negotiated down by my Medicare hmo.

There is no doubt that our medical care system needs a complete overhaul, and I'm afraid we are not going to get it.  I agree fully with the the authors final paragraph. 


PSA up to 4.7 July 2006 , nodule noted during DRE
Biopsy 10/16/06 ,stageT2A
Very Aggressive Gleason 4+4=8  right side
DaVinci Surgery  January 2007
Post op confirms gleason 4+4=8 with no extension or invasion
no long term continence problems
Post surgery PSA continues to be "undetectable"
One side nerves spared
Bi-Mix for ED 
born in 1941


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 7/9/2009 10:54 AM (GMT -6)   
Fun With Numbers.

Engineer’s point that the costs of active surveillance go on year after year got me to thinking.
Let us assume that a man who is 60 years old is diagnosed with prostate cancer, does active surveillance, and dies of something else at age 82.
We could then add up the cost for treatment for the rest of his life (back of the envelope accuracy) and we could take into account health care inflation.
0% inflation $26,000
3% inflation $35,000
7% inflation $55,000
10% inflation $77,000 (about the current medical inflation figure)

So, at 7% the best economic deal is get the guy to have a prostectomy, give him a new car (economic stimulus) and save over $10,000!
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0


JoeyG
Regular Member


Date Joined Jul 2009
Total Posts : 162
   Posted 7/9/2009 11:49 AM (GMT -6)   
I am kinda on the optimistic side with the possible overhaul of healthcare. There is a lot of input from all sides going in and one really has to think that the final result will be something totally better than what we have now. On the negative side, discussion of cost containment seems to concentrate more on treatment strategies rather than focusing more on lowering actual costs. Healthcare and pharmaceutical providers must be shown that they can lower their unit charges because they will benefit by higher volume due to the inclusion of those who are not served or who are underserved in the present system. 
 
One other thing- even in the present system, in all too many cases our health insurers will only cover the least cost alternatives, particularly for drugs.
 
I constantly focus on this as this process evolves---President Obama's Mother died of cancer and was underserved by the system. I would hope that he would be sensitive to cancer sufferers because of that. He ceratinly has said as much, many times.
Age -57; Diagnosed 10/05 PSA 13.4 GS 9 Organ confined
Cryoablation 4/06 Allegheny Hosp-Dr Ralph Miller (Cohen/Miller)
Post Cryo Nadir 8/06 0.2
Rising steadily to 0.7 4/09 :-(
Looking to take next steps soon
Hoping to qualify for salvage cryo or radiation


don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 7/9/2009 2:03 PM (GMT -6)   
Hi Tony,
 
The article is interesting. The emphasis on the cost vs result is a valid argument. However, I would question why the cost is so high to begin with. I have read that part of the reason is that there are relatively more providers chasing a relatively small group of patients. For instance, in my place of residence there are two non profit hospitals. (Both have been on a building spree for the last eight years. Must be making a lot of "non profit" tongue ) Anyway, in addition to the NP's there are two other private radiation centers. All have the same equipment with one exception. Population of the metro area is around 350000 and it is relatively isolated from other major metro areas. Nearest is 350 miles. When I did my research I tried to get bids from the providers thinking that with four in the area surely there would be some leverage. Not so. Only one was even willing to talk about the cost and some form of discount for cash. Attitude from the rest was "it will cost what it costs and we will tell you what that is when we are through." Point is that lack of competition and a captive market allow the providers to charge whatever they want. Few patients have the financial resources to pursue treatment outside of their immediate area.
 
End of rant. turn
 
Don
 
 
 
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Lupron injection on May 15 and every four months for next two years
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 to be full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones 
 
 
 


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4204
   Posted 7/9/2009 3:15 PM (GMT -6)   
It's fun to play with numbers and compare AS to Surgery as if there is no after costs to surgery or other treatments. You still have to get PSA tests at least every year and have follow up doctor's visits, and there are ongoing costs dealing with the complications such as ED meds and incontinance issues. At least 30% will have some sort of salvage or HT treatments.

This is a difficult issue and the author brings out some very good points, but I for one don't want a Bureaucrat in Washington determining what treatments I should have. Maybe we should have a minimum standard and let people who want more buy additional insurance. We have different levels of coverage for auto and home insurance, why not health insurance. I can't accept having my choices limited by Washington.

I've read some related articles and it looks like Proton treatment for PC is on the firing line. Some insurance companies and Medicare are looking into dropping Proton coverage in favor of IMRT because of the cost benefit; Kaiser won't pay for Proton. A lot of insurance companies, mine included, won't pay for Robotic because it shows no benefit over open or laprascopic surgery. And these are the simple issues. When we start to look at the cost benefits of many of the drugs we open a whole new can of worms.
I guess we can always go to Mexico to get the treatments we want.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT


wd40
Regular Member


Date Joined Jan 2008
Total Posts : 218
   Posted 7/9/2009 4:03 PM (GMT -6)   
Arrogant seems to be the key word here. As much as we complain about insurance cost it is the insured ability to pay that made medical research financially rewarding then through that advances in medical care.

If we use this same argument from the article then why should the insurance company pay for high blood pressure medicine if you are not at the perfect weight, don't eat meat or salt, exercise daily and chant something to reduce stress.

Less also remember medical care means jobs here in the USA.
12/06/07 DaVinci and open prostate surgery after difficulties in breathing stopped the davinci.


lifeguyd
Veteran Member


Date Joined Jul 2006
Total Posts : 674
   Posted 7/9/2009 4:18 PM (GMT -6)   
John T said...
It's fun to play with numbers and compare AS to Surgery as if there is no after costs to surgery or other treatments. You still have to get PSA tests at least every year and have follow up doctor's visits, and there are ongoing costs dealing with the complications such as ED meds and incontinance issues. At least 30% will have some sort of salvage or HT treatments.

This is a difficult issue and the author brings out some very good points, but I for one don't want a Bureaucrat in Washington determining what treatments I should have. Maybe we should have a minimum standard and let people who want more buy additional insurance. We have different levels of coverage for auto and home insurance, why not health insurance. I can't accept having my choices limited by Washington.

I've read some related articles and it looks like Proton treatment for PC is on the firing line. Some insurance companies and Medicare are looking into dropping Proton coverage in favor of IMRT because of the cost benefit; Kaiser won't pay for Proton. A lot of insurance companies, mine included, won't pay for Robotic because it shows no benefit over open or laprascopic surgery. And these are the simple issues. When we start to look at the cost benefits of many of the drugs we open a whole new can of worms.
I guess we can always go to Mexico to get the treatments we want.
JohnT

John
Unlike you, I have more faith in the bureaucrats in Washington than I have of the bureaucrats in the private sector.  Regulation is everywhere and all of the private bean counters are worse than the public bean counters.  I am willing to cut the government a break dispite recent history.  Private enterprise has sc####d me over more time than I can count.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25372
   Posted 7/9/2009 4:20 PM (GMT -6)   
When I was on BlueCross BlueShield of SC, they didn't care if it was robotic or open, it was my choice all the way, and that would have gone for Proton or IMGT, again, my choice. I am now on my wife's insurance, and they are even more open.

Must vary state to state.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 5/9 .10, 6/9 .11, July 13 - meet with radiation oncologist
 
 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25372
   Posted 7/9/2009 4:23 PM (GMT -6)   
lifeguyd, i tend to agree with you, years of having unregulated "free enterprise" medical costs rising out of the world hasn't helped any of us. that's why we pay such ridiculous amounts for meds that are cheap anywhere else in the world.

i am willing to give the new admin a chance at this, already has the drug companies, the AMA, and the hopsitals willing to deal, that's never happened before
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 5/9 .10, 6/9 .11, July 13 - meet with radiation oncologist
 
 


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4204
   Posted 7/9/2009 6:08 PM (GMT -6)   

lifegyd,

I guess you have never been treated in a govt run VA hospital or ever had to wait 7 months for a VA claim to be processed (still waiting). I'll take my chances with the private sector anyday. I spent 4 mos in a VA Hospital and it was no fun. I've seen the low cost solution, apathetic staff, poor doctors and 3 tries to get anything done right.

I checked into in the emergency room at my local hospital Tuesday night with chest pains. I was on a machine in less than 20 sec and in 1 hour I had two EKGs, chest Xrays,  and complete lab analysis. It turned out to be low potassium. I was treated like I had checked into the Ritz Carlton.

JT


lifeguyd
Veteran Member


Date Joined Jul 2006
Total Posts : 674
   Posted 7/9/2009 7:45 PM (GMT -6)   
John T said...

lifegyd,

I guess you have never been treated in a govt run VA hospital or ever had to wait 7 months for a VA claim to be processed (still waiting). I'll take my chances with the private sector anyday. I spent 4 mos in a VA Hospital and it was no fun. I've seen the low cost solution, apathetic staff, poor doctors and 3 tries to get anything done right.

I checked into in the emergency room at my local hospital Tuesday night with chest pains. I was on a machine in less than 20 sec and in 1 hour I had two EKGs, chest Xrays,  and complete lab analysis. It turned out to be low potassium. I was treated like I had checked into the Ritz Carlton.

JT

I think we are talking about apples and oranges.  I agree that the VA has had it's difficulties, however so do 100's of private hospitals.  I am not talking about the government running hospitals, I'm talking about the government regulating and yes offering a fair affordable medical plan.  They already do it with Medicare.  I am happy to report that while on Medicare I have never had a complaint, nor a procedure denied or a problem with my paper work.  I pay my partB and a supplement and get virtually 100% coverage including Rx drugs.

If they can do it for retirees, they can do it for everyone.  It will cost more, but everyone should be required to pay their fair share.

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