Peter C. Albertsen, MD

 Editorial Council, is professor of surgery and chief of urology at the University of Connecticut Health Center, Farmington.

Research by Sun et al presented at the AUA annual meeting just scratches the surface of the complexity of health care resource consumption and appropriate health care. The authors note that 5% of patients with newly diagnosed prostate cancer consumed 23% of health care resources utilized by men with newly diagnosed prostate cancer in 2009.

This conclusion is not surprising and is simply a variation of the well-known Pareto principle. Named for the Italian economist Vilfredo Pareto, who noted in 1896 that 20% of Italians owned 80% of the land, the 80/20 rule has proven remarkably accurate in many economic situations. Researchers have demonstrated that 20% of Medicare recipients in general consume 80% of Medicare resources. This rule is not limited to prostate cancer patients.

What drives costs of prostate cancer care?

Health care costs continue to escalate and are becoming an increasingly important political issue in the U.S. The current financing mechanisms are no longer sustainable. Most European countries control health care costs through budgets. The NHS in the United Kingdom has a very explicit methodology to determine if new pharmaceuticals, especially anti-cancer drugs, and other new medical technologies will be funded. Most new treatments are evaluated according to their cost per life-year saved.

The U.S. has a very different model of health care delivery that depends primarily on the ability to pay. Most Americans have some form of health insurance that they use to help pay for the care they receive. More and more expenses, however, are either only partially covered or not covered at all. Furthermore, insurance companies are more frequently demanding co-pays or mandating pre-authorization before covering discretionary care.

We must all participate in this health care debate. When healthy, we are often reluctant to pay health care premiums or resent increases in taxes to cover Medicare and Medicaid services. When sick, however, we want only the best for ourselves and our family. We expect others to help us shoulder the costs of nursing home care for our parents or expensive chemotherapy for ourselves or our spouse.

The health care industry-including pharmaceutical companies, device companies, surgeons, and medical doctors-has the ability to constantly innovate. This is a good thing when new treatments lead to substantial gains in returning people to productive, healthy lives. Unfortunately, it is a bad thing when treatments simply prolong suffering and do not lead to independent living. Deciding what care is appropriate is already extraordinarily difficult but will be a growing problem for the next generation of physicians and society.

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"Deciding what care is appropriate is already extraordinarily difficult but will be a growing problem for the next generation of physicians and society," writes Peter C. Albertsen, MD.

Prostate cancer study highlights complexity of ‘appropriate’ care

There is no doubt that robot-assisted radical prostatectomy is more expensive than an open prostatectomy performed through a lower midline incision or a perineal approach. A recent report in the 

(2010; 363:701-4) stated that a robotic prostatectomy adds about $2,200 per operation for additional supply costs and operating room time. In addition, capital costs and maintenance add $400 to $4,800, depending upon the utilization of a specific machine.  

What does the patient or society gain from the additional resources expended? Extensive marketing by surgeons and hospitals suggests major advantages, but proponents of robot-assisted radical prostatectomy have been unable to document them. At a 2-day conference, the world's leaders in robotic surgery performed an exhaustive review of the world's literature (

 2012; 62:368-81). They concluded that robotic prostatectomy achieves cancer control equivalent to that of the more traditional open prostatectomy and may offer advantages in the postoperative recovery of urinary continence and erectile function. I suspect that experienced, high-volume surgeons performing either robotic or open procedures will have remarkably similar outcomes. 

Editorial Council, is professor of surgery and chief of urology at the University of Connecticut Health Center, Farmington. 

Higher costs without greater benefits means that robotic procedures are at risk of not being supported by efforts to control health care costs.

Peter C. Albertsen, MD

Articles

Prostate cancer study highlights complexity of ‘appropriate’ care

Robotic vs. open radical prostatectomy: Who pays the cost?