Tuesday, November 4, 2014

New Technology in Prostate Biopsies

On the professinal side, I am often looking at new opportunities to screen, diagnose, or treat and asking the economic question--what makes this a good buy?  Some, of course, migth simply say, "It is more effective so why would we not want to use resources for it?"  And given the value that is assigned to life, that is often a reasonable supposition.  However, given the limited resources that are available for medical care and public health efforts, it is also often worth while to ask a few deeper questions and determine whether a use of resources is the best use of resources or not.  

On the personal side, my blogging began with a memorial service for a fellow parent at my kids' elementary/middle school who lost a battle with prostate cancer.  So, when there are new ways to guide screening, biopsies, and making a progosis, they almost always catch my interest.

An article in today's Wall Street Journal focused on the potential use of MRI's to guide biopsies to determine whether prostate cancer is agressive and should be treated agressively or whether it is more likely that the tumor, despite its presence, is clinically insignificant.

The article does a good job of describing everything that would go into an economic, cost-effectiveness evaluation without doing one and without, it appears, one having been completed so far.  Specifically, there is a higher cost to have the MRI prior to the biopsy--but from the patient's point of view some of that is paid by the insurer.  There are some aggressive cancers that are detected by the MRI technique and, as importantly, some cases that are rules as "not signficant" after which a patient can avoid being over treated.  Then, to make matters more complicated, there are also a fair number of cases missed despite the MRI.

Thus, an economic evaluation would have to compare the clear and readily identified cost of the procedure (potentially from different perspectives) with the value of more appropriate identification of aggressive cancers and the value of avoiding over-treatment (not just lower costs but potentially better quality of life that results from avoiding the side effects of surger to remove the prostate like incontinence and sexual dysfunction, and then account for the costs associated with still missed cases.

This would not be a simple analysis.  And while we may have quality of life and life expectancy measures for each of the resulting outcomes, this is a complicated situation in which the fear of a missed case or the disappointment with finding out that the cancer was not as bad as expected should be taken into account.  These types of quality of life issues are dynamic and complex.  

How should a decision be made?  The technology has some distinct advantages.  These should be presented to patients.  However, this does seem to call for shared decision making between the patient and urologist with as much information as possible shared in a way that is comprehensible until there is clear data to suggest whether the MRI is truly economically preferred.