November, 2013

Five for Fighting

By Michael J. Katin, MD

This has been, needless to say, a very eventful past few weeks in the medical field. There was the first report of effectiveness of a malaria vaccine, giving hope to reduce the death toll of over 600,000 children in sub-Saharan Africa every year. The web site, healthcare.gov, was launched. The biggest story, however, was the declaration of "Five Wise Health Care Decisions" by the American Society for Radiation Oncology. This is in keeping with the 2011 program of the American Board of Internal Medicine Foundation, "Principles Guiding Wise Choices."

"Principles Guiding Wise Choices" is a comprehensive statement of the problems facing modern medicine and the possible solutions. The preamble, which has 208 words compared to 52 for the preamble of the Constitution of the United States, expresses concern about overuse of procedures when the population of the United States is aging (10,000 people reaching age 65 every day). There is, however, no comment on the need to work harder to produce cures for these people. Presumably there are far more important things on which to expend resources than health.

A short two years later, ASTRO has come up with its contribution to the Wise Choice program. These are five items intended to make an impact on the future of medical care:

Wise Choice One: Don't initiate whole breast radiotherapy as a part of breast conservation therapy in women age greater than or equal to 50 years with early stage invasive breast cancer without considering shorter treatment schedules
Wise Choice Two: Don't initiate management of low-risk prostate cancer without discussing active surveillance
Wise Choice Three: Don't routinely use extended fractionation schemes (greater than 10 fractions) for palliation of bone metastases
Wise Choice Four: Don't routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry
Wise Choice Five: Don't routinely use intensity modulated radiation therapy (IMRT) to deliver whole breast radiotherapy as part of breast conservation therapy.

It should be observed that ASTRO has managed to come up with a list entirely made up of things NOT to do. Even the Ten Commandments had only 70% "shall-not's."

I was particularly impressed by Wise Choice #1, which implies that women age 50 and above do not warrant treatment currently considered standard. We previously dealt with the possibly overstated encouragement for treatment with hormonal therapy alone vs. radiation therapy and hormonal therapy.full in women over 70 wondering if that was being overly discriminatory!!!.

Perhaps there will later "Wise Choices" about what we should be doing, but in the meantime it might be worth evaluating these five items. Why were there five rather than four, six, or ten? It is because five is a sacred number in Freemasonry, or that there are five elements in Feng Shui? Is it a reference to the pentagram? Or, more ominously, is it a sign of a fifth column working within our profession, especially considering that the announcement was made only shortly before the article in The New England Journal of Medicine attributing overuse of intensity-modulated radiation therapy to the profit motive of urologists? No one would ever seriously consider this, but our survival may be sabotaged regardless.

Those in the practice of radiation oncology will no doubt question the reason to curtail proven methods of treatment for carcinoma of the breast and prostate. Is the motivation to shorten treatment times for patients when the dedication of only a few weeks may result in long-term disease control without complications? Receiving a treatment that takes 15 to 30 minutes a day should not impose an intolerable burden on the average person. If the thought is to minimize expense---well, that's actually already been accomplished thanks to the 20 per cent cuts in the fee schedule over the past several years by CMS. If it is to do treat to the very best way known by evidence-based, medicine, isn't it more rational to settle this before making suggestions? In terms of internal consistency, note the number of reports from ASTRO's 55th Annual Meeting on the use of IMRT in treatment of carcinoma of the breast and on the use of proton beam therapy in treatment of carcinoma of the prostate. Should these have been put into a politically incorrect session, perhaps three days after the regular meeting?

Is it not paradoxical that for the past thirty years the trend has been away from extensive surgery and toward conservative management of malignancies, resulting in the decrease in the number of modified radical mastectomies and radical prostatectomies, not to mention radical head and neck surgical procedures? In that case, why is it so unreasonable that urologists should decide that radiation therapy is an appropriate treatment for prostate cancer and want to make it part of their practice? There may be a fine line between "vested interest " and "enlightenment." It may be that Jean M. Mitchell, Ph.D., the author of the NEJM article, being located at Georgetown University, is surrounded by government officials for whom most decisions are made based on their own profit motives.

It may turn out years from now that accelerated partial breast irradiation may be appropriate for some women and that molecular profiling (usually costing at least $3,000 to $4,000) may identify patients with carcinoma of the prostate that can safely have active surveillance, but it seems premature to deliberately make a commitment to reduced treatment options immediately. This would be similar to deciding to stop requiring automobile manufacturers to have all vehicles equipped with seat belts and air bags in order to reduce expenses, since the chance of dying in an automobile accident is only 1 in 18,585 (the chance of being injured by a toilet this year being 1 in 10,000) and the use of these devices reduces this by 45% (dying in an automobile accident, not the toilet injury).

While we are trying to continue to maintain our role in cancer treatment against aggressive efforts to minimize the value of what we do, this is the same as expecting to have a successful season in the NFL without using your starting quarterback It's like deliberately making sequels to The Fast and the Furious without Vin Diesel. . It's even like trying to run a marathon with a 93-pound refrigerator on your back...not that anyone would ever do that.

Maybe instead of trying to maximize restrictions on the practice of radiation oncology, ASTRO should add Wise Choice Six: Don't implement Wise Choices One through Five until they are proven.

Thanks to Keith Miller for his astute contribution.