Why Is There So Much Resistance to Active Surveillance?

BY RALPH BLUM

Multiple studies have shown that the survival rate of men with early stage low-risk prostate cancer who choose Active Surveillance, matches that of men who choose immediate surgery, and without all of the attendant risks. Men who choose Active Surveillance are enthusiastic about having dodged the double bullets of erectile dysfunction and loss of urinary control. So if the virtues of active surveillance are so obvious, and major medical centers like Johns Hopkins are reporting excellent results with their active surveillance program, why are prostates still being removed at a record pace?

One reason is the pressure on for-profit private hospitals to boost the volume of procedures in a bid to hold onto huge annual profit margins. And the 2,900 non-profit hospitals across the country, which are exempt from income taxes, actually end up averaging higher profit margins than the 1,000 for-profit hospitals—in one case more than $500 million in the fiscal year 2010.

I’m not suggesting that these jaw-dropping profit margins are solely the result of the drastic over-treatment of men with prostate cancer. However, there is also no doubt that prostate cancer is a multi-billion dollar industry.

Take surgical robots: The so-called Da Vinci Robotic system, broadly acclaimed as “state of the art” for prostate surgery, costs more than $1 million to acquire and install. Roughly $1,500 worth of parts must be replaced after every procedure. The Da Vinci System is now in use in more than 1,000 hospitals and clinics across the country. When a hospital invests that much money in a surgical robot and trains surgeons to use it, the pressure is huge to sell surgery over other treatments.

So the advent of robot-assisted prostatectomies has significantly increased the number of surgeries performed each year. Nationally, 80% of men over age 70 with low-risk disease are either undergoing radiation or having their prostates removed unnecessarily. Yet there is a confluence of new evidence that men with a PSA of less than 10 who had surgery gained no benefit from the procedure; that in many cases, no treatment is the best treatment.

Of course what Ted Turner calls “serious cash money” is not the only reason for the radical over-treatment of prostate cancer.  Even though 91% of men with this disease will have a normal life expectancy, a diagnosis of prostate cancer leaves most men reeling and, in many cases, with an overwhelming desire to “just cut it out”—despite the risks and life disrupting side effects one can expect if the delicate nerve-sparing surgery doesn’t go as planned. Yet according to prostate experts at Johns Hopkins, if urologists separated out men with low-risk disease and entered them in an Active Surveillance program, prostatectomies would dramatically decline and patients would be better off.

Research is currently underway at Johns Hopkins to further refine the protocols for separating out low-risk, slow-growing prostate cancers from the high-risk, aggressive cancers. And it is worth noting that, in the meantime, of the hundreds of men who have been enrolled in Hopkins’ Active Surveillance program, not a single patient has died of prostate cancer.