Estudo publicado no 'Journal of Medical Care' sugere que a maneira como os homens são tratados de câncer de próstata parece ser influenciada por uma variedade de fatores, inclusive a tecnologia disponível e as metas de marketing de hospitais e médicos, mais do que a evidência científica cotejando benefícios e riscos.
Hospitals With Robots Do More Prostate Cancer Surgery (NYT)
By TARA PARKER-POPE
Chris Garlington for The New York Times Robots assist surgeons in performing prostate cancer surgery in a growing number of medical centers.
Hospitals that buy surgical robots end up performing more prostate cancer operations, suggesting that technology has become a driving force behind decisions about men's cancer care, new research shows.
The study, published in the journal Medical Care, is the latest report to suggest that how men are treated for prostate cancer appears to be influenced by a variety of factors, including the technology and marketing goals of hospitals and doctors, rather than scientific evidence on benefits and risks.
For men facing prostate cancer, the findings add more uncertainty to an already confusing array of choices for treatment, with little evidence to guide them about whether one is better than another. Current options include surgery to remove the prostate gland, performed with or without the assistance of robots, as well as radiation and hormone therapies. And because prostate cancer is often slow-growing, active surveillance without treatment is also an option for many men.
The new study, conducted by researchers at New York University and other institutions, tracked surgical robot purchases at 554 hospitals, along with the treatment given to more than 30,000 men given a prostate cancer diagnosis from 2001 to 2005.
According to the study, when a hospital acquires surgical robots, men in that region are more likely to have surgery to treat prostate cancer than before the technology was acquired. Buying a robot led to an average increase of 29 operations a year per hospital. Meanwhile, hospitals that didn't invest in robots performed an average of five fewer operations annually. Although large hospitals may perform hundreds of such operations a year, many of the local and regional hospitals in the study see no more than 100 to 150 cases a year, the study authors said.
One reason for the increase in operations in hospitals that own a surgical robot may be that the technology helps a hospital lure potential surgical patients away from the competition. But the data also suggest that once a hospital obtains a robot, patients who might be candidates for nonsurgical options are more likely to be steered toward robotic surgery instead.
"This may be the medical embodiment of the phrase, 'If you're a hammer, everything looks like a nail,'"said the lead study author, Dr. Danil V. Makarov, assistant professor of urology at New York University's Langone Medical Center. "If you have the technology, it will get used.''
Researchers note that over all, the number of operations declined slightly during the study period, possibly reflecting a plateau in cancer cases or a shift to other treatments. But when the data were examined at the hospital and regional levels, the researchers found that the purchase of a robot was associated with a pronounced change in treatment trends.
The findings are concerning because surgical removal of the prostate, called radical prostatectomy, can result in a number of complications, including incontinence and impotence. Robotic surgery typically costs about $2,000 more than regular surgery, but it's not clear whether its outcomes are better, worse or the same as traditional surgery, or how it compares to other treatments or even doing nothing at all.
Some research suggests the robotic procedure reduces hospital stays and blood loss, compared with regular surgery, but studies have also shown that robotic surgery offered no added benefit or worse results. In addition, when the Agency for Healthcare Research and Quality in 2008 compared the effectiveness and risks of eight prostate cancer treatments, including surgery, radioactive implants and active surveillance, no single treatment strategy emerged as superior.
But that hasn't stopped hospitals from conducting intense marketing campaigns that imply surgery using the high-tech robot gives prostate cancer patients a better result.
Surgical robots are expensive. A surgical robot used for prostate cancer costs $1 million to $2.25 million, according to the N.Y.U. study. In addition, hospitals spend $140,000 annually for a service contract and $1,500 to $2,000 per patient on disposable instruments.
"If you're a hospital and you get a robot, clearly you want to use it,'' said Dr. David Penson, a study co-author and director of the Center for Surgical Quality and Outcomes Research at Vanderbilt University. "There are some real pressures here that have nothing to do with science," he said. "We have this interplay of patients' fascination with technology coupled with business interests on the part of the hospital and device makers, pushing people to try a new technology perhaps before it's been fully tested.'' He said he performs traditional prostate cancer surgery, though his practice offers robotic surgery as well.
Dr. Makarov, who is trained to perform both the traditional and robotic procedures, added that while financial incentives are likely to play a role in which treatments are promoted, patients also often want the newest technological advance, and hospitals are simply responding to that demand.
A study published last year in The Journal of Clinical Oncology tracked the treatment of 11,892 men given a prostate cancer diagnosis. About half the men opted for surgery. Among the remaining men, 14 percent were given hormone therapy; 13 percent were given radioactive seed implants; 12 percent had external-beam radiation; 5 percent had cryoablation, which destroys prostate tissue through freezing; and about 7 percent selected active surveillance, in which the cancer is closely monitored for changes, but no treatment is given.
The researchers found that treatment patterns varied markedly across the clinical sites studied, and those differences could not be explained by measurable factors like severity of disease or patient age.
In addition, recent reports, including an investigation of Medicare billing by The Wall Street Journal and the nonprofit Center for Public Integrity, also suggest that financial incentives to doctors and radiology groups are driving patients to a new form of radiation therapy called intensity modulated radiotherapy, or I.M.R.T. Patients are often referred to I.M.R.T. treatment centers by doctors who have a financial stake in the practice.
"For patients, there are a lot of choices in prostate cancer,'' said Dr. Makarov. "Knowing that technology can influence both what they want and what their physician may advise them should make them a little more skeptical and maybe make them ask a few more questions.''
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