Men diagnosed with prostate cancer face a significant choice: undergo the potential risks of surgery to remove the cancer or monitor the cancer and risk that it spreads to other areas of the body.
Results of a 20-year national study led by a researcher at the Minneapolis VA Medical Center make that decision more complicated. The results provide the best evidence yet that most men can live with their prostate cancers and avoid the potential risks of surgery. But the results did show that for younger men with prostate cancer and a longer life expectancy, surgery may be the right option.
Prostate cancer is the most common cancer in American men after skin cancer according to the American Cancer Society. It’s so common that about one in seven men will be diagnosed with prostate cancer during his lifetime.
This may sound like a lot, but remember that prostate cancer develops mainly in older men. About 6 in 10 cases are diagnosed in men aged 65 or older and while it can be a serious disease, most men will not die from it.
Some men have said they are worried these results will encourage insurance companies to convince patients not to pursue costly treatments. The decision for everyone involved is based on the best long-term health of the patient, quality of life and the cost of treatment. These factors are complicated by the unknown – the possibility that the cancer may spread.
Insurance companies have a vested interest in promoting the health of their enrollees. Early detection and treatment are well worth the cost. At the same time, insurers also have an obligation to be good stewards of the money we all pool through our premiums.
So how do insurers decide which evidence and studies to base these decisions on and how are the decisions made? According to an expert at Medica, it’s all about the quality of the research, best practices and case history.
- Quality of Research
Most insurance companies rely on Hayes Ratings, which evaluates new research and new treatments and technologies based on their quality and effectiveness. Hayes looks at things like who published the research, where it’s been published and the volume of the research. This independent evaluator helps insurance companies and doctors determine the best course of treatment for each case.
Insurers also look at indicators that the research is sound. They consider the size of the pool of participants and evaluate reasons for causation instead of association. For example, there has recently been a lot of research published linking ADHD and obesity but there is no research that shows one causes the other, only that the two are associated.
- Best Practices:
In general, treatments are approved for specific conditions, but may not be authorized for all uses of that treatment. As technology advances, many researchers find that technology that works for one health issue can be effective for others. Insurance companies look at how treatments have worked on similar cases in the past and may approve it if the best practice shows that it can be effective.
This is also true for treatment plans. When doctors and patients agree to continue care after a procedure, the likelihood of success increases. For example, insurance companies rarely deny hip and knee replacements because after-care plans are commonly in place before the surgery.
- Case History:
Every case is different and insurers recognize that. While some treatments work for most patients, there are special cases that require special consideration. A strong case from a patient’s doctor can make the difference in what insurers recognize as appropriate treatment. Cases showing effective treatments can also be helpful to set benchmarks for future patients with similar case histories.
Insurers have a responsibility to use the money people pay in premiums wisely. When a patient with prostate cancer pushes for surgery, they have to weigh the risks and the reward. Even though surgery may seem like the best option, it’s sometimes riskier from both a health and investment standpoint than monitoring the cancer.
Insurers also are respectful of the doctor-patient relationship. While statistics are valuable, every patient is an individual. Everyone shares the long-term goal of a positive outcome. It also is typical for insurers to have a review process. If a claim is denied, most insurance companies have an appeal process to review the case.
Medical research is constantly evolving and while tools like Hayes can help judge the accuracy, insurance companies rely on feedback from medical professionals and patients for the best information.