Health Care Decisionmaking

Quality-of-life issues complicate decisions about prostate cancer screening

Annual screening of asymptomatic men for prostate cancer, beginning at age 50, remains controversial. Screening may detect microscopic cancers that are not detrimental to the patient. Yet treatments such as surgery and radiation can result in rectal injury, impotence, and urinary incontinence, as well as death (1 percent mortality rate for radical prostatectomy).

Different experts offer conflicting recommendations on prostate cancer screening—for example, the American Cancer Society says yes, but the U.S. Preventive Services Task Force says no. Unfortunately, better data won't be available for years, but patients and providers have to make decisions now, using imperfect data.

A recent study concludes that, if life expectancy is the only criterion for the screening decision, and cost is not a factor, annual screening of asymptomatic men may extend a patient's life expectancy by a few months. However, when one considers how an individual man assesses the impact of screening and possible treatment on his quality of life, screening is not recommended, according to researchers at the University of Texas.

The researchers used a decision-analytic model to evaluate the outcomes of annual screening for prostate cancer beginning at age 50 using digital rectal examination, transrectal ultrasound, and the prostate-specific antigen (PSA) test. The investigators interviewed a sample of 10 patients with no history of prostate disease to assess their preferences regarding the various adverse outcomes of prostate cancer treatment, using the time trade-off method. This method is used to determine the amount of life expectancy in a suboptimal state of health (for example, incontinent or impotent) a patient would be willing to trade for a shorter life expectancy in perfect health.

When men were presented with being screened and treated aggressively for detected cancer, radiation was barely preferable to surgery for the early stages of cancer. They preferred the no-screening strategy to the screening strategy by 8 quality-adjusted life months (presumably living for 8 months without the side effects of treatment such as rectal injury, incontinence, or impotence). Only if quality-of-life considerations were disregarded, was screening preferred to no screening.

Although only a small sample (10) of asymptomatic men were involved in this study, the researchers believe that an optimal screening decision depends on the patient's evaluation of potential adverse outcomes. Thus, they urge physicians to carefully weigh patient preferences when making recommendations about prostate cancer screening.

The results of this study were presented in part at a 1993 conference sponsored by the Agency for Health Care Policy and Research. More details are in "Prostate cancer screening: A decision analysis," by Scott B. Cantor, Ph.D., Stephen J. Spann, M.D., Robert J. Volk, Ph.D., and others, in The Journal of Family Practice 41(1), pp. 33-41, 1995.

Aggressive treatment for localized prostate cancer may be unwarranted in older men

Men over 65 years of age with slow-growing,localized prostate cancer who receive conservative management with hormone therapy may live as long as the general population. This finding, which is based on a study supported by the Agency for Health Care Policy and Research (HS06770), suggests that aggressive radiation treatment and surgery for low-grade prostate cancer tumors, which can result in impotence and incontinence, may be unwarranted in older men.

The researchers, led by Peter C. Albertsen, M.D., of the University of Connecticut Health Center, used records from 37 acute care hospitals and 2 Veterans Affairs medical centers to compare the outcomes of elderly men diagnosed with clinically localized prostate cancer from 1971 to 1976. At that time, immediate or delayed hormonal therapy was the most common treatment for localized prostate cancer among older men.

More than 15 years later, the age-adjusted survival of untreated men with low-grade, localized prostate cancer was not significantly different from those who were conservatively treated. On the other hand, untreated men with moderate-grade tumors (regional metastasis) potentially had as much as 4 to 5 years less life expectancy, and those with high-grade tumors (distant metastasis) potentially had as much as 6 to 8 years less life expectancy compared with the general population.

Tumor characteristics and coexisting patient illnesses were powerful independent predictors of survival and should be factored into decisions about treatment, according to the researchers. They conclude that prospective randomized trials are the only way to judge the ability of more aggressive treatment to save potentially lost years for patients with moderate- and high-grade tumors of the prostate.

See "Long-term survival among men with conservatively treated localized prostate cancer," by Dr. Albertsen, Dennis G. Fryback, Ph.D., Barry E. Storer, Ph.D., and others, in the Journal of the American Medical Association 274(8), pp. 626-631, 1995.

Health services research plays a pivotal role in health care decisionmaking

The share of Federal spending on health care devoted to health services research dropped from 1 percent to .1 percent between 1970 and 1994. Yet health services research is needed more than ever by consumers, health plans, and others, according to Clifton R. Gaus, Sc.D., Administrator of the Agency for Health Care Policy and Research, and Acting Deputy Administrator, Lisa Simpson, M.B., B.Ch, M.P.H., in a recent editorial.

Health services research can increase understanding about what works and what doesn't work in managed care, and findings from health services research can inform consumers about the risks and benefits of available treatments and the quality of services provided by individual clinicians. Further, health services research is also needed to identify the information most likely to assist consumers and employers in choosing health plans and to aid decisions by accrediting groups and State regulators.

The evolving health care system is being driven by market forces and competition rather than regulation, according to Drs. Gaus and Simpson. Its success will depend on the ability to generate the information needed to inform choices and reward consumer, purchaser, provider, or health plan behaviors that promote quality and constrain costs. The government plays an essential role in generating this information to ensure that it is science-based, objective, and widely disseminated.

Nevertheless, this Federal role must be carried out in partnership with the private sector, as exemplified by several recent AHCPR initiatives. The authors conclude that, beyond strengthening existing partnerships and building new ones, health services research should "reinvent" itself to respond to its challenges.

Further details are in "Reinventing health services research," by Drs. Gaus and Simpson, in the Summer 1995 issue of Inquiry 32, pp. 130-134.

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