Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [112]
88 For the staging of prostate cancer, including the Gleason score, see Mack Roach III et al., “Staging for prostate cancer,” Cancer 109 (2007), pp. 213–220; Sadeq Abuzallouf, Ian Dayes, Himu Lukka, “Baseline staging of newly diagnosed prostate cancer: A summary of the literature,” Journal of Urology 171 (2004), pp. 2122–2127. A description of a prostate biopsy and ultrasound examination is found in Jerome Groopman, “The prostate paradox: There are new techniques for fighting the cancer: But when should we use them?” New Yorker, May 29, 2000.
91 Optimal therapy of prostate cancer is widely debated among medical experts. The U.S. Agency for Healthcare Research and Quality commissioned a review of treatments of prostate cancer, seeking to identify which approach might be superior in terms of either maximum cure or least side effects. A committee of nine experts, led by Dr. Timothy Wilt of the Minneapolis VA Health Care System, compared surgery, radiation, hormonal therapy, and active surveillance (“watchful waiting”). They also looked at several less common options, like cryotherapy, which quickly freezes and thaws cancer cells to destroy them. The group’s analysis was guided by input from urologists, oncologists, primary care physicians, radiation therapists, and patients. The committee examined more than seven hundred published studies, assessed doctors and hospitals, patient databases, surveys, and clinical trials, weighed side effects, and evaluated survival outcomes. The conclusion was that no one treatment was superior, that all had downsides, and that fewer side effects developed among patients treated by surgeons in medical centers that performed more operations. Where the doctor stood depended largely on where he or she sat, meaning surgeons favored surgery, radiation oncologists favored radiation therapy. Notably, only a small number of doctors favored watchful waiting, although the expert panel could not discern whether this approach might be superior or inferior to the active interventions of operation and radiation.
The results of this expert analysis came as a surprise to some, since the notion that served as the basis for the review was that if specialists carefully weighed existing information, key advantages and disadvantages of the different treatment options would be identified, so-called comparative effectiveness, and a clear idea of what is “best” and for whom would become apparent. See commentary on Dr. Wilt’s effort: Jenny Marder, “A user’s guide to cancer treatment,” Science 326 (2009), p. 1184.
Also of note, there were regional differences in the percentage of patients with prostate cancer who received different therapies. This was most striking with regard to watchful waiting, where about 7 percent of men in New England chose this approach versus 14 percent in the Pacific states and 13 percent in the mountain region: Agency for Healthcare Research and Quality, “Effective health care: Comparative effectiveness of therapies for clinically localized prostate cancer,” Executive Summary, February 2008; Timothy J. Wilt et al., “Systematic review: Comparative effectiveness and harms of treatments for clinically localized prostate cancer,” Ann Intern Med 148 (2008), pp. 435–448.
92 Matt Conlin’s age and the cutoff of sixty-five years old used by the surgeon might be derived from one study indicating a survival benefit from surgery for men at or below that age: Anna Bill-Axelson et al., “Radical prostatectomy versus watchful waiting in early prostate cancer,” NEJM 352 (2005), pp. 1977–1984. A follow-up study published in 2011 showed that the survival benefit was sustained: Anna Bill-Axelson et al., “Radical prostatectomy versus watchful waiting in early prostate cancer,” NEJM 364