Re: Economic Scene - Plan to Cut Medicare Without Stifling Innovation - NYTimes.com

[Guest guest]

Kathy,

If you compensate for documented ASTRO versus 0.2 ng/ml measurement

bias

(+17% at 10 years), relative cohort disease levels (from 2% to 8% over

RP) and then compare the best treatment results for each treatment type

you might find some interesting information for a follow-on article.

Almost no PCa treatments are equally good, although some are closer

than others.

A

comparison of long term treatment effectiveness and serious

side effects that was assembled by six previous PCa patients can be

found at

www.rcogpatients.com.

For a quick review of the comparisons click on the "Snapshot" button at

the bottom of

the first page.

Carl

Kathy Meade wrote:

The treatment of prostate cancer offers a good example of the

trouble with

the current system. I devoted a column to prostate cancer last year,

and the

Health Affairs article - by Pearson of Massachusetts General

Hospital

and B. Bach of Memorial Sloan-Kettering Cancer Center - uses it

as a

case study, too.

The brief version is that the options for treating prostate cancer

include

three forms of radiation. One of them, three-dimensional radiation,

costs

Medicare about $10,000. Another treatment, a targeted form of radiation

known as I.M.R.T., came along a decade ago and initially cost about

$42,000.

Lately, Medicare has also started covering a third, proton radiation

therapy, for which it pays $50,000.

No solid research has shown I.M.R.T. to be more effective at keeping

people

alive, with minimum side effects, than three-dimensional radiation. The

backing for proton therapy is weaker yet. As Dr. Pearson says, "There is

even less evidence on whether proton therapy is as good as other

alternatives than there was for I.M.R.T. when it was the new kid on the

block."

But Medicare today doesn't pay for good outcomes. It pays for any

treatment

that it deems reasonable and effective.

http://www.nytimes.com/2010/10/20/business/economy/20leonhardt.html?_r=1 & ref

=health

[Guest guest]

Carl P wrote:

> If you compensate for documented ASTRO versus 0.2 ng/ml

> measurement bias (+17% at 10 years), relative cohort disease

> levels (from 2% to 8% over RP) and then compare the best

> treatment results for each treatment type you might find some

> interesting information for a follow-on article. Almost no PCa

> treatments are equally good, although some are closer than

> others.

> A comparison of long term treatment effectiveness and serious

> side effects that was assembled by six previous PCa patients

> can be found at www.rcogpatients.com. For a quick review of

> the comparisons click on the " Snapshot " button at the bottom of

> the first page.

I didn't find anything on the pages at rcogpatients.com that

explained how these numbers were adjusted for PSA, Gleason score,

stage, or age. Did I miss it?

One of the pages says: " The average failure rates listed above

only apply to the best treatment center for each treatment type " ,

but I didn't see a listing of those treatment centers or any

information about how the statistics were gathered from each or

how the adjustments (if any) were applied.

ly, this looks to me like a sales pitch for ProstRcision and

the company that offers it.

I've seen a lot of reports like this one and I don't trust them.

I saw one article once that claimed a 96% success rate for HDR

brachytherapy, including 100% for low risk patients. Is that

report right or is 58.1% success rate from " the best treatment

center " as reported by rcogpatients right? Or are both of them

wrong?

I saw a report once claiming 97.5% success for surgery at a

certain clinic. I've read reports from patients who have been

told by their surgeons that 98% of their patients regain full

sexual function - and when the patient doesn't, it's " Oh my! Bad

luck! You're in the 2%. "

There are big bucks at stake here and the stockholders of the

private clinics can gain or lose millions of dollars based on how

successful they are in convincing patients that they offer the

very best treatment.

I'm not ready to give any credence to that web page.

Alan

[Guest guest]

Kathy Meade wrote:

> The treatment of prostate cancer offers a good example of the

> trouble with the current system. I devoted a column to prostate

> cancer last year, and the Health Affairs article - by

> Pearson of Massachusetts General Hospital and B. Bach of

> Memorial Sloan-Kettering Cancer Center - uses it as a case

> study, too.

>

> The brief version is that the options for treating prostate

> cancer include three forms of radiation. One of them,

> three-dimensional radiation, costs Medicare about $10,000.

> Another treatment, a targeted form of radiation known as

> I.M.R.T., came along a decade ago and initially cost about

> $42,000. Lately, Medicare has also started covering a third,

> proton radiation therapy, for which it pays $50,000.

>

> No solid research has shown I.M.R.T. to be more effective at

> keeping people alive, with minimum side effects, than

> three-dimensional radiation. The backing for proton therapy is

> weaker yet. As Dr. Pearson says, " There is even less evidence

> on whether proton therapy is as good as other alternatives than

> there was for I.M.R.T. when it was the new kid on the block. "

>

> But Medicare today doesn't pay for good outcomes. It pays for

> any treatment that it deems reasonable and effective.

>

>http://www.nytimes.com/2010/10/20/business/economy/20leonhardt.html?_r=1 & ref=he\

alth

>h

I consider the New York Times to be one of the most reliable

sources of news but I wish that Mr. Leonhardt, the reporter, had

done more homework on that article.

To begin with, I'd like a little clearer discussion of prices.

He said that 3D radiation cost $10,000 and IMRT " initially cost

about $42,000 " . What is the cost comparison today?

Then there's the question about effectiveness. There is good

evidence that increasing the dose of radiation increases the cure

rate. But the problem with increasing the dose is that it also

increases toxicity to healthy tissue - which can cause severe

side effects.

Both IMRT and proton therapy aim to reduce the dose to healthy

tissue as compared to 3DCRT. That enables higher doses to be

delivered to the cancer while staying within safe parameters for

the patient.

I don't know if there have been clinical trials comparing the

three forms of external beam radiation. It's entirely possible

that there have not. But it is my understanding that there have

been well designed studies to show that increasing the dose

improves outcomes and also well designed studies to show that the

safe dose limit for 3DCRT is lower than for the other two forms.

So the desire of patients to get the more advanced forms of

radiation is not just an irrational wish for the latest

technology.

I'm not saying the author of the article is wrong. He might be

right. The question he raises is legitimate. But I wish he had

explained the dosage and toxicity issues and given strictly up

to date cost numbers in the article.

Alan

[Guest guest]

I’m not going into all the ins and

outs of this beyond saying that it seems impossible to estimate accurately the

cost of various therapies on offer in the USA. In the first place there is

the work-up and follow-up which may differ from therapy to therapy but

which can add up to thousands of dollars, but the main variance seems to be

what pressure can be put on the supplier of the therapy to reduce their prices.

I tried to do a bit of work on this

subject earlier in the year when approached by a South Korean PBT (Proton Beam

Therapy) centre which was offering to carry out the therapy of some $35,000 and

said this compared very favorably with the $150,000 charged by some US centres. What

I found was a very broad range of costs quoted in the US for this,

from about $28,000 at one centre for a limited number of men who could

demonstrate their inability to pay more to well over $100,000 for, well, others

who could afford to pay more.

I tried the same approach to Surgery

recently in the light of some discussion that Active Surveillance was a

more costly option than Surgery. Since I had been quoted $21,000 for an RP

(Radical Prostatectomy)by a surgeon in the US in 1997 – for his work, plus

of course on costs – and on the assumption that there might possibly have

been an increase in costs in the intervening 13 years I could not reconcile

some of the figures used in the AS comparisons. I was told by a leading US

surgeon that his team had tried to establish these figures (presumably so he

could ensure that he stayed at an appropriate level in the market) but it was

simply not possible.

Just a bit of a diversion to say, beware

of anyone making cost comparisons in this time. From what I read the ‘Obama/Medicare’

debate hasn’t gone away and there’ll be more spin around than there

is in the tornado season.

All the best

Prostate men need enlightening, not

frightening

Terry Herbert - diagnosed in 1996 and

still going strong

Read A Strange Place for unbiased information at http://www.yananow.net/StrangePlace/index.html

From: ProstateCancerSupport [mailto:ProstateCancerSupport ] On Behalf Of Alan Meyer

Sent: Friday, 22 October 2010

12:00 PM

To: ProstateCancerSupport

Subject: Re:

Economic Scene - Plan to Cut Medicare Without Stifling Innovation

- NYTimes.com

Kathy Meade

wrote:

> The treatment of prostate cancer offers a good example of the

> trouble with the current system. I devoted a column to prostate

> cancer last year, and the Health Affairs article - by

> Pearson of Massachusetts

General Hospital

and B. Bach of

> Memorial Sloan-Kettering Cancer

Center - uses it as a

case

> study, too.

>

> The brief version is that the options for treating prostate

> cancer include three forms of radiation. One of them,

> three-dimensional radiation, costs Medicare about $10,000.

> Another treatment, a targeted form of radiation known as

> I.M.R.T., came along a decade ago and initially cost about

> $42,000. Lately, Medicare has also started covering a third,

> proton radiation therapy, for which it pays $50,000.

>

> No solid research has shown I.M.R.T. to be more effective at

> keeping people alive, with minimum side effects, than

> three-dimensional radiation. The backing for proton therapy is

> weaker yet. As Dr. Pearson says, " There is even less evidence

> on whether proton therapy is as good as other alternatives than

> there was for I.M.R.T. when it was the new kid on the block. "

>

> But Medicare today doesn't pay for good outcomes. It pays for

> any treatment that it deems reasonable and effective.

>

>http://www.nytimes.com/2010/10/20/business/economy/20leonhardt.html?_r=1 & ref=health

>h

I consider the New York Times to be one of the most reliable

sources of news but I wish that Mr. Leonhardt, the reporter, had

done more homework on that article.

To begin with, I'd like a little clearer discussion of prices.

He said that 3D radiation cost $10,000 and IMRT " initially cost

about $42,000 " . What is the cost comparison today?

Then there's the question about effectiveness. There is good

evidence that increasing the dose of radiation increases the cure

rate. But the problem with increasing the dose is that it also

increases toxicity to healthy tissue - which can cause severe

side effects.

Both IMRT and proton therapy aim to reduce the dose to healthy

tissue as compared to 3DCRT. That enables higher doses to be

delivered to the cancer while staying within safe parameters for

the patient.

I don't know if there have been clinical trials comparing the

three forms of external beam radiation. It's entirely possible

that there have not. But it is my understanding that there have

been well designed studies to show that increasing the dose

improves outcomes and also well designed studies to show that the

safe dose limit for 3DCRT is lower than for the other two forms.

So the desire of patients to get the more advanced forms of

radiation is not just an irrational wish for the latest

technology.

I'm not saying the author of the article is wrong. He might be

right. The question he raises is legitimate. But I wish he had

explained the dosage and toxicity issues and given strictly up

to date cost numbers in the article.

Alan

[Guest guest]

Alan,

I appreciate you taking the time to review the rcogpatients PCa

comparison

"Snapshot" charts. The information you are looking for can be found in

the body

of the site but I will also attach it, including all references,

to this email. Unfortunately, the way we provided it is clearly not

obvious so

we will change that in our next update early next year. The

information in the attachment can also be found by clicking on the

Summary "button" at the bottom of the first page of the website, then

go to page iii and click on the word (here).

The same information can also be found in the main section

of the website by clicking on the Index "button" at the bottom of the

first page, then clicking on page 34 and then the word (here).

This site was generated and updated by six previous

Radiotherapy Clinic of Georgia (RCOG) patients. It is not advertising

for RCOG and we just want to try to help newly diagnosed PCa patients

do their "homework". There are many viable choices for treatment

besides RCOG especially considering all the reasons a man picks a

treatment and treatment center, in addition to reported numbers.

The reason the "best comparable numbers we could find" were used was to

make the comparison as straight forward as possible. All patients

should

understand that there is a large range of outcomes reported for each

treatment type and center or doctor and that their individual treatment

could be

severely compromised if they just go to the nearest center or doctor

(although the nearest one may be just fine - or not).

Hope I answered your questions.

Carl

Alan Meyer wrote:

Carl P

wrote:

> If you compensate for documented ASTRO versus 0.2 ng/ml

> measurement bias (+17% at 10 years), relative cohort disease

> levels (from 2% to 8% over RP) and then compare the best

> treatment results for each treatment type you might find some

> interesting information for a follow-on article. Almost no PCa

> treatments are equally good, although some are closer than

> others.

> A comparison of long term treatment effectiveness and serious

> side effects that was assembled by six previous PCa patients

> can be found at www.rcogpatients.com. For a

quick review of

> the comparisons click on the "Snapshot" button at the bottom of

> the first page.

I didn't find anything on the pages at rcogpatients.com that

explained how these numbers were adjusted for PSA, Gleason score,

stage, or age. Did I miss it?

One of the pages says: "The average failure rates listed above

only apply to the best treatment center for each treatment type",

but I didn't see a listing of those treatment centers or any

information about how the statistics were gathered from each or

how the adjustments (if any) were applied.

ly, this looks to me like a sales pitch for ProstRcision and

the company that offers it.

I've seen a lot of reports like this one and I don't trust them.

I saw one article once that claimed a 96% success rate for HDR

brachytherapy, including 100% for low risk patients. Is that

report right or is 58.1% success rate from "the best treatment

center" as reported by rcogpatients right? Or are both of them

wrong?

I saw a report once claiming 97.5% success for surgery at a

certain clinic. I've read reports from patients who have been

told by their surgeons that 98% of their patients regain full

sexual function - and when the patient doesn't, it's "Oh my! Bad

luck! You're in the 2%."

There are big bucks at stake here and the stockholders of the

private clinics can gain or lose millions of dollars based on how

successful they are in convincing patients that they offer the

very best treatment.

I'm not ready to give any credence to that web page.

Alan

1 of 1 File(s)

Prostate Cancer Treatment Comparisons.doc

[Guest guest]

Alan,

I will answer your next round of (quite reasonable) questions in red

below:

Alan Meyer wrote:

wrote:

> I appreciate you taking the time to review the rcogpatients PCa

> comparison "Snapshot" charts. The information you are looking

> for can be found in the body of the site but I will also attach

> it, including all references, to this email.

Thanks. That helps a lot. I apologize for failing to find the

data on the website. [Not your fault, it wasn't

east to find.]

I appreciate the work that you and others put into this. I

appreciate that the patients make no money from this. I

appreciate the sophisticated work that you have done in putting

all of the information together.

However I still have reservations.

On the adjustments to the numbers, I notice that ProstRcision

numbers were multiplied upward by 3.1% to compensate for more

advanced patients [compared to RP; go to the

index and look at

page 15 and then click on (More Info) to see how the RCOG/RP

calculation

was done], but I see no indication that any other numbers

were similarly adjusted, [look at the write up I

sent, a few were

estimated

because some reports didn't mention PSA group

distributions.

It appears in each type PCa treatment paragraph.]

for which I would

expect they should have been. Surely it couldn't be

the case that all of the

treatment centers had the same mix of patient

characteristics

except RCOG, which treated higher risk patients on

average [look at the treatment descriptions for your answer].

I'm also more inclined

towards stratified numbers rather than

adjusted numbers, i.e., here are the results for low risk,

intermediate risk, and high risk patients, though I understand

that some of the sources for data may not have provided that.

Stratified numbers are more clearly justifiable than adjusting

the outcome - which makes it look to the average patient that he

has an 86.6% chance of a successful outcome when the data shows

an 84% chance. [We attempted to level the

playing field.]

Interestingly, the description of ProstRcision:

"Radioactive Seeds followed by Intensity Modulated Radiation

Therapy (IMRT)"

looks similar to the description of one of the others:

"IMRT followed by Radioactive Seeds"

The only obvious difference being seeds followed by IMRT vs. IMRT

followed by seeds [There is a significant

difference and at least two

treatment

centers tried the same thing about 10 years ago and had

to

give it up due to high levels of serious side effects. RCOG found

out

how to resolve those problems. Some centers are now trying it

again

but none of them have 10 year data.]

Do you have a theory about what accounts for the different treatment

failure rates:

29.6% vs. 13.4%, a ratio of 2.2:1? [RCOG's

explaination

is (1) simultaneous IMRT while

the radioactive seeds are still at

energy levels above the first 60

day half life do a better job

"destroying" the prostate

material; (2) the radioactive seeds and a

couple of gold seeds permit more

accurate aiming of the IMRT on

the prostate and therefore more

effective "eventual destruction" of

the prostate material (this also helps to

minimize serious side effects);

and (3) the requirement for

RCOG doctors to have 1 year of residency

and 100 supervised treatments

results in higher average 10 year (0.2 ng/ml)

disease free results.]

I know I'm a cynic, but isn't that suspicious to you?

Do the RCOG

doctors think that the other clinic can cut its

failure rate in half by giving

seeds first, then IMRT? [yes,

if they trained their doctors/technicians

better an invoked dual

redundancy quality control like RCOG in all of

their treatment steps they would probably

do much better.]

As far as I know, nobody audits the figures published by the

different clinics. I was told by a prostate cancer researcher

working on PSA bounce statistics that he appealed to a number of

clinics for raw data but not one of the four well known centers

that he approached would show him anything.

They said they couldn't show him anything due to patient

confidentiality issues. He offered to sign confidentiality

agreements and, after all, he was a doctor. They wouldn't do it.

He offered to pay their clerk to black out names on copies of the

medical records before they were given to him. Still no dice.

He appealed to them on the grounds that he was working for the

National Cancer Institute, not one of their competitors, and the

information would benefit the whole cancer community. They

didn't care. Basically, they all told him to get lost.

I'm not saying that RCOG cheats, and as far as I know they are an

excellent place to get treatment. But having statistics better

than anyone else is worth many millions of dollars to them and if

they do cheat on the numbers, they can be very confident that

they will never be caught. [All of their medical

journal reports went

through a peer review by

non-RCOG doctors. My understanding

is that some access to their

data base, which is very extensive, may

have been allowed but that may have been 6

years ago before the rules

tightened up. By the way,

RCOG published one of the first medical

journal reports on bounce

statistics. I can look it up for you if you want.]

It's the wild west in cancer treatment. Caveat emptor! [i fully agree.

Carl]

Alan

[Guest guest]

Terry Herbert wrote:

>I don’t pretend to even begin to understand cost calculations in

>the US , but Chuck’s figures are nowhere near these (or the

>figures sent in to me from men who had PAID the fees)

>

>Here is a summary of what is estimate as the total 10-year

>revenue stream for the urology practice from a low-risk prostate

>cancer patient who is covered by Medicare:

....

I am reminded of a comment by the famous physicist

Feynman. He was speaking about the wave / particle duality, but

he could equally well have been talking about medical charges in

the U.S. He said:

" If this doesn't confuse you, you don't understand it. "

I'm pretty sure that hospital charges would not be included in

the " revenue stream for the urology practice " , and that they

would be far, far larger than the charge by the urologist

himself. They will include the operating theater, nurses,

bedroom, tests, drugs, anaesthesiologist, pathologist,

administrators, social workers, floor sweepers, and who knows

what else.

Alan

[Guest guest]

Alan.

Excellent indeed!

Ever try?

Ever fail?

No matter.

Try again.

Fail again.

Fail better. Beckett

Re: Economic Scene - Plan to Cut Medicare

Without Stifling Innovation - NYTimes.com

> Carl P wrote:

>

>> I appreciate you taking the time to review the rcogpatients PCa

>> comparison " Snapshot " charts. The information you are looking

>> for can be found in the body of the site but I will also attach

>> it, including all references, to this email.

>

> Thanks. That helps a lot. I apologize for failing to find the

> data on the website.

>

> I appreciate the work that you and others put into this. I

> appreciate that the patients make no money from this. I

> appreciate the sophisticated work that you have done in putting

> all of the information together.

>

> However I still have reservations.

>

> On the adjustments to the numbers, I notice that ProstRcision

> numbers were multiplied upward by 3.1% to compensate for more

> advanced patients, but I see no indication that any other numbers

> were similarly adjusted, which I would expect they should have

> been. Surely it couldn't be the case that all of the treatment

> centers had the same mix of patient characteristics except RCOG,

> which treated higher risk patients on average.

>

> I'm also more inclined towards stratified numbers rather than

> adjusted numbers, i.e., here are the results for low risk,

> intermediate risk, and high risk patients, though I understand

> that some of the sources for data may not have provided that.

> Stratified numbers are more clearly justifiable than adjusting

> the outcome - which makes it look to the average patient that he

> has an 86.6% chance of a successful outcome when the data shows

> an 84% chance.

>

> Interestingly, the description of ProstRcision:

>

> " Radioactive Seeds followed by Intensity Modulated Radiation

> Therapy (IMRT) "

>

> looks similar to the description of one of the others:

>

> " IMRT followed by Radioactive Seeds "

>

> The only obvious difference being seeds followed by IMRT vs. IMRT

> followed by seeds.

>

> Do you have a theory about what accounts for the different

> treatment failure rates: 29.6% vs. 13.4%, a ratio of 2.2:1?

>

> I know I'm a cynic, but isn't that suspicious to you? Do the

> RCOG doctors think that the other clinic can cut its failure

> rate in half by giving seeds first, then IMRT?

>

> As far as I know, nobody audits the figures published by the

> different clinics. I was told by a prostate cancer researcher

> working on PSA bounce statistics that he appealed to a number of

> clinics for raw data but not one of the four well known centers

> that he approached would show him anything.

>

> They said they couldn't show him anything due to patient

> confidentiality issues. He offered to sign confidentiality

> agreements and, after all, he was a doctor. They wouldn't do it.

> He offered to pay their clerk to black out names on copies of the

> medical records before they were given to him. Still no dice.

> He appealed to them on the grounds that he was working for the

> National Cancer Institute, not one of their competitors, and the

> information would benefit the whole cancer community. They

> didn't care. Basically, they all told him to get lost.

>

> I'm not saying that RCOG cheats, and as far as I know they are an

> excellent place to get treatment. But having statistics better

> than anyone else is worth many millions of dollars to them and if

> they do cheat on the numbers, they can be very confident that

> they will never be caught.

>

> It's the wild west in cancer treatment. Caveat emptor!

>

> Alan

>

>

>

>

>

> ------------------------------------

>

> There are just two rules for this group

> 1 No Spam

> 2 Be kind to others

>

> Please recognise that Prostate Cancerhas different guises and needs

> different levels of treatment and in some cases no treatment at all. Some

> men even with all options offered chose radical options that you would not

> choose. We only ask that people be informed before choice is made, we

> cannot and should not tell other members what to do, other than look at

> other options.

>

> Try to delete old material that is no longer applying when clicking reply

> Try to change the title if the content requires it