Treated differently or a…”different kind of patient?”

Study confirms prostate cancer is treated differently at county vs. private hospitals

January 25, 2010

Researchers at Moores Cancer Center at the University of California, San Diego and colleagues have found that prostate cancer treatments varied significantly between county hospitals and private providers. Patients treated in county hospitals are more likely to undergo surgery while patients treated in private facilities tend to receive radiation or hormone therapy. These findings were published online by the journal Cancer on January 25.

“The study examined the factors that drive treatment choices for patients with prostate cancer” said J. Kellogg Parsons, MD, MHS, principal investigator and urologic oncologist at Moores UCSD Cancer Center. “We found that decisions are significantly influenced by the type of health care facility where they receive care.”

Surgery, radiation and hormone therapy are the most common treatments for localized prostate cancer. Each is associated with different risks and benefits with no consensus as to the most effective form of treatment, though life expectancy, other illnesses, cancer severity and patient preferences may account in part for treatment choices. Parsons and colleagues at UCLA compared the types of treatments prostate cancer patients received from public and private hospitals as part of a California public assistance program. The researchers analyzed the care provided to 559 men enrolled in a state-funded program for low-income patients known as Improving Access, Counseling and Treatment for Californians with Prostate Cancer (IMPACT).

Between 2001 and 2006, 56 percent of the study participants received treatment from county hospitals and 44 percent received care from private facilities. While tumor characteristics were similar in each group, patients treated in private facilities were more likely than those treated in county hospitals to be white and less likely to undergo surgery. Specifically, patients treated in private facilities were nearly two-and-a-half times more likely than those treated in county hospitals to receive radiation and more than four-and-a-half times more likely to initially receive hormone therapy instead of surgery.

While the reasons for these differences in treatment decisions are not known, the type of doctor that patients see may play a role, according to Parsons. At county hospitals, patients were initially under the care of urologists, while the initial providers at private facilities represented urologists, radiation oncologists, and medical oncologists.

“The fact that prostate cancer patients are treated differently based on the type of hospital has implications for health policy, quality of care and equality of care-particularly because public hospitals are funded by city and state governments to provide health care for underserved, poor populations,” said Parsons.

After skin malignancies, prostate cancer is the most commonly diagnosed cancer, and the second leading cause of cancer death among U.S. men.

University of California – San Diego

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My thoughts

Here’s the thing. Implied but not stated is that  county means “lower socio-economic and less educated” and private implies “better educated and richer.” I am not touting my book, really, but, I have consistently noted in it and in my twenty-four career as a urologist that the majority of the time the patient chooses what to do about his prostate cancer based on “who he is.” I have said for years that CEO’s (decisive, take action types) will almost always choose surgery. The internet guy, (reading reports and going it alone because he can surf the net) will almost always choose the fancier course. The guy in overalls will do what the doctor recommends ( often times the wisest course). In my book, “The Decision” , I make the point that what you decide depends on numerous “who are you ” factors.

In the above  piece, the private hospital types are less likely to choose surgery, not because it is inferior, they are choosing what they think is  “slick” , trendy, or perceived as  smart. Often times they will choose “designer ” options. This “private” type is more likely to value ease of treatment and the one least likely to disrupt their lifestyle. You get the drift. If you are a cure only type, simple-minded, straight forward in thinking and might want surgery. A “get it out type.”  If you have read about something new, something you feel is the latest greatest, and want your “cake and eat it too, you might choose something other than surgery. So , I see this article really being more about, not cancer and availability of specialists, than about what type of patients are more likely to be found at each. In a way it is a politcal article with the author making a subliminal point that county patients don’t get good care and are railroaded to surgery by me.. the urologist. Oh yes, I will always(ha ha) recommend surgery.

Here’s the dirty little secret. In a few years when this same type article is written comparing county to private hospitals, robotic surgery will the one most done at the private hospital. Robotic, don’t you love that name, it sounds so cutting edge, appeals to the “informed” group and socio-economically able to do any of the treatments.  Article after article have come out to say that there is no improvement in the things that matter, potency, cure, incontinence, but yet it is now becoming the treatment and modality of choice in the newly diagnosed prostate cancer patient. The choice of the informed prostate cancer patient. ( I know I chose robotic, but I did for one specifice reason- a slight edge about getting back to work sooner.)

Summary: In the next study the finding will be that the person at the private hospital is more likely to have robotic than open prostatectomy. That study will mean something, and the appropriate conclusion will be made for the right reasons in that study, as opposed to this one that misses the mark.   “who are you” and what you decided to do are intimately connected.

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