Point of View: What Are We Doing? The Incredible Expense and Uncertain Value of Localized Prostate Cancer Diagnostic and Therapeutic “Advances”

Abstract

You have accessJournal of UrologyPoint of View1 Feb 2024Point of View: What Are We Doing? The Incredible Expense and Uncertain Value of Localized Prostate Cancer Diagnostic and Therapeutic “Advances” Daniel D. Joyce, Christopher P. Filson, and Lindsey A. Herrel Daniel D. JoyceDaniel D. Joyce *Corresponding Author: Daniel D. Joyce, MD, Department of Urology, Vanderbilt University Medical Center, A1302 Medical Center North, Nashville, TN 37232-2765 ( E-mail Address: [email protected] https://orcid.org/0000-0003-4365-8622 Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee More articles by this author , Christopher P. FilsonChristopher P. Filson Department of Urology, Kaiser Permanente, Los Angeles, California More articles by this author , and Lindsey A. HerrelLindsey A. Herrel Department of Urology, Michigan Medicine, Ann Arbor, Michigan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003798AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail The recent landscape of prostate cancer care has been transformed by novel diagnostic imaging studies, molecular biomarkers, advanced pharmaceutical agents, and technologically advanced treatment modalities. Creation of these novel diagnostic and therapeutic tools was undoubtedly motivated by desires to decrease the burden of cancer-related death and abrogate detrimental impacts on quality of life related to cancer treatment. One success story in this domain was development of novel therapeutics for patients with metastatic prostate cancer, such as abiraterone and enzalutamide. The trials leading to approval of these agents showed improvements in overall survival, which has since been reflected with population-level improvements in survival among patients with metastatic prostate cancer in the US.1 For those with localized disease, many technological advancements for cancer care that have been adopted have not had a clear impact on cancer-related survival or quality of life. For instance, the rapid adoption of robotic assistance for performing radical prostatectomy emerged in the absence of any evidence of superior cancer control with the minimally invasive approach.2 Proton beam radiation therapy carries substantially higher costs compared to intensity-modulated radiation therapy, and no evidence of decreased toxicity during its early adoption.3 Incorporation of prostate MRI for biopsy guidance slightly increases detection of higher-grade tumors,4 but there is no evidence of an impact on cancer survival with that approach to date. Some have proposed that biopsy targeting via prostate imaging may promote overdiagnosis and overtreatment of prostate cancer.5 Tissue-based genomic tests have been adopted broadly (albeit inconsistently) without clear evidence of improvements in cancer-specific survival associated with their use.6 Treatment with expensive oral therapies for low-risk prostate cancer on active surveillance is supported by some based on recent clinical trial data, despite others in the urologic oncology community lobbying to rename these indolent diseases noncancerous.7 Finally, though there are seemingly innumerable focal therapy modalities for men with more favorable disease, there is a paucity of comparative effectiveness evaluations demonstrating superiority in cancer control vs active surveillance. Incentives that promote incorporation of new tools into clinical practice are pervasive throughout the health care system, and urologists are not immune to these forces. Some of these incentives are financial in nature. Urologists with ownership of prostate cancer treatment technologies such as radiation vaults or in-office drug dispensing are more likely to treat men with those technologies and often treat men who are at a low risk of dying from prostate cancer.8,9 Promotional payments to urologists from pharmaceutical companies are strongly as