Monday, January 9, 2017

They are at it Again!

Prostate Cancer is a multifaceted malignancy. BRCA2 genes can make the result explosive and lead to rapid death. Many however are indolent. Knowing how to select which is which has not yet been achieved.

In a recent article a physical writes in Health Affairs:

The indolent nature of many prostate cancers has heightened concerns that harms from treatment may outweigh those from the disease and has resulted in a growing consensus in favor of less aggressive screening and treatment. We sought to understand the population-level impact of this consensus on the treatment of prostate cancer. Using national Medicare data for the period 2007–12, we assessed treatment rates among men with newly diagnosed prostate cancer. We identified both population-based rates (which are sensitive to changes in diagnosis and treatment patterns) and rates among diagnosed men (which are sensitive only to changes in treatment patterns). We also assessed trends in treatment among men with a high risk of noncancer mortality, who are unlikely to benefit from treatment. Population-based treatment rates declined by 42 percent, while rates among diagnosed men declined by only 8 percent. Treatment rates among men with the highest noncancer mortality risk and regional variation were unchanged. These results suggest that decreasing rates of diagnosis, changing attitudes, and guidelines calling for reduced prostate-specific antigen screening, not changes in practice patterns among specialists treating diagnosed men, drove the decline in population-based treatment rates. Compared to policies that emphasize volume, those that emphasize value in specialty care have the potential to exert stronger effects on practice patterns. 

Read the last sentence carefully. Value. It is like Quality. It has not absolute meaning and it would appear that as it is in the eye of the beholder and not the patient, well you guess it. That was the core of the ACA. Not any per-existing condition, but who gets to decide who lives and who dies.

Now read Science Daily which reflects on this article:

The researchers recommend new payment models or other policies that emphasize value of care over volume, which might provide more incentive for specialists to choose observation over treatment. They also urge participation in quality improvement initiatives, such as the Michigan Urological Surgery Improvement Collaborative, which strive to provide high quality, evidence-based care.
In addition, research continues to uncover new clues to identify which men are at highest risk of aggressive prostate cancer and could most benefit from screening and treatment. "That's really the concern here. We know prostate cancer is a deadly disease in some men. We need better tools to identify which men should be screened and among those diagnosed, which men should be treated aggressively. This is still a black box. It's that uncertainty that leads to different approaches to treatment based on how different physicians view the risk. If we get better predicting who's at highest risk, we can more accurately tailor screening and treatment," 

The statement is in my opinion grossly arrogant. The physician gets to decide if the patient should be treated? Really? What about the patient. After all he has paid for this. So we just let him die because some academic decides to do so. 

Why does the ACA need to be repealed and redone? Life versus Death, the patient versus the system.