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Prostate cancer technology: Is less more?

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The data are not convincing that one form of newer technology is superior to the traditional lower-cost prostate cancer treatments they replace (eg, robotic vs. open prostatectomy and photon vs. proton radiation).

Dr. Gomella, a member of the Urology Times Editorial Council, is chair of the department of urology, Jefferson Kimmel Cancer Center, Thomas Jefferson University, Philadelphia.

The impact of technology on the prostate cancer treatment “arms race” continues to evolve. There is concern about overuse of expensive technology for a

Dr. Gomelladisease that may not impact a man’s life. The data are not convincing that one form of newer technology is superior to the traditional lower-cost prostate cancer treatments they replace (eg, robotic vs. open prostatectomy and photon vs. proton radiation).

Recent changes in treatment recommendations for localized prostate cancer have been dramatic, with more discussion of active surveillance versus active treatment. Up to 50% of men with screen-detected prostate cancer are candidates for active surveillance.

New technology is rapidly expanding and many men with prostate cancer may not derive additional benefit from these costly interventions. Concerns abound that the need to recoup the technology investment might encourage increased utilization. Industry and health systems continue to promote high-priced robotic surgical and radiation technology while editorialists question the self-referral conflict of urologist-owned radiation facilities.

In the study by Schroeck et al, the increased penetration of robotic surgical units was associated with more surgery and less radiotherapy. While this suggested that technology does not increase treatment rates for prostate cancer, another question is why was there no reduction in overall treatment rates due to active surveillance? This study from 2003-2007 was during the early days of active surveillance. Of note, the National Comprehensive Cancer Network did not add active surveillance to its prostate cancer treatment guidelines until 2010. We await a more contemporary review of technology utilization in the context of increased active surveillance.

However, the potential impact of technology costs on active surveillance will also need to be considered. Current active surveillance, the least costly option for low-risk disease, utilizes routine prostate biopsy and laboratory testing. Active surveillance is entering its own technology phase as genomics and MRI costs may ultimately impact these cost savings.

A fatal flaw that we all must take ownership of is the concept that “if it costs more, it must be better.” In the modern world of prostate cancer technology and active surveillance, perhaps “less is more” should be considered the new mantra.UT

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