A structural problem in our health system means many men with prostate cancer do not understand their treatment options and are being funnelled into expensive surgery.

When a man is suspected of having prostate cancer, the first medical specialist he will see is a urologist.

As urologists make the diagnosis, they are the gate keepers of treatment. And as they are surgeons, they are more likely to recommend surgery, says Sandra Turner, associate professor of radiation oncology at Sydney University.

While different interventions are possible, the two main treatment options are surgery or radiation therapy (RT).

Turner says a potential conflict of interest arises because the gatekeepers make money out of surgery and nothing out of radiation therapy.

PRICE DIFFERENTIAL

For patients there is a price differential too. With cutting edge surgery in the private sector men are commonly out of pocket $10,000.

Both surgery and RT, however, are available free in the public sector.

Turner says in NSW and Victoria, while 60 per cent of radiation therapy is bulk-billed in the public sector, more than 75 per cent of prostatectomies are performed privately with large gap fees.

“I believe men have the right to hear all options directly from the experts involved and that’s not happening across the board.”

“But urologists have no training in RT, they are not up with the literature or new techniques and are not in a position to discount it as an option.”

“Many men and their general practitioners do not have the faintest idea that high-tech curative radiation is equally effective and has low rates of side effects. ”

Turner says the rate of prostatectomies, particularly with a robot, is increasing while the rate of radiation therapy as an initial therapy is on the decline.

According to the Victorian prostate cancer registry, when treatment is necessary, 48 per cent of men have surgery and 18 per cent have radiation therapy.

Turner notes recent research shows more men regret having surgery than radiation.

MULTI-DISCIPLINARY ADVICE

A national association is now being formed to provide cohesive multidisciplinary advice to men with prostate cancer. It’s being formed by the Urological Society of Australia and New Zealand, the Faculty of Radiation Oncology Genito-urinary Group and the Medical Oncology Group of Australia.

Mark Frydenberg president of the Urological Society says urologists are no more “gatekeepers” than any other surgical specialists who arrange and perform a biopsy, take the case to a multidisciplinary team meeting and arrange care.

He says most urologists recommend a direct referral to a radiation oncologist but if a man doesn’t want to go, he can’t be forced.

As urologists counsel men regarding the relative cancer outcomes, they do have a role in discussing radiation therapy with patients.

“There is no more a conflict of interest with urologists recommending surgery than a radiation oncologist recommending radiation to a patient,” he says.

Frydenberg says if there was a conflict of interest, why are so many men referred for active surveillance or RT?

In cases where men require radiation therapy after surgery, he says it’s not because surgery failed but because of planned multimodal therapy.

The Urological Society encourages men to be fully informed and seek additional opinions from a surgeon, a radiation or a medical oncologist.

For information on RT see: www.targetingcancer.com.au