EURURO Vol. 72 No. 5

737 860

uncertainty. As a result, Schroek and colleagues may still
be overestimating the cost-effectiveness of newer technolo-
gy. Evaluation against the ‘‘wrong’’ comparator in treatment
trials and cost analyses is one factor leading to the authors’
proclaimed ‘‘revolution in prostate cancer treatment’’ In
the US, direct-to-consumer marketing of new technologies
, opportunities for self-referral and a quantity versus
quality based reimbursement model further feed into
overdiagnosis and overtreatment that contribute to spiraling
health care costs.
SR, including those of treatment costs, provide a critical
role in helping us reflect on the appropriateness of medical
care and guide future evidence-based decision-making
. This is particularly true in prostate cancer; a prevalent
and potentially fatal disease with a highly variable natural
history. Schroeck et al note: ‘‘Understanding the value of
treatment with new technologies will become increasingly
important as society and policy makers are moving towards
accountable care organizations, bundled payments, and
value based reimbursement.’’ They also highlight that cost
utility may depend on the time horizon (early high
acquisition costs, treatment harms, and lack of benefit
versus later lower operational costs, harms reduction, and
mortality/morbidity benefits) and the payer perspective
(patient, insurer, society, costs, versus charges). Unfortu-
nately, consideration of resource use remains an under-
utilized component for optimizing health care value
delivery. In theory, expensive interventions, including those
studied by Schroeck et al should only be implemented
based on reliable evidence demonstrating greater benefits
or fewer harms than less expensive options (higher value).
However, historically, more expensive technologies have
rarely proven to be higher value. Early adoption of more
expensive technologies prior to demonstration of better
value has much to do with the pathway by which new
technologies are approved including lower evidentiary
standards by the US Food and Drug Administration than
used for pharmaceutical therapies .
Where do we go for here? Decision makers need higher
quality evidence summarized in well performed SR of
comparative benefits, harms, and resource utilization to
make well informed decisions. Aside from its approach for
making clinical practice guidelines, the Grades of Recom-
mendation, Assessment, Development, and Evaluation
Working Group has recently developed an approach for
moving from evidence to decisions including those about
coverage . Ideally, evidence should be available prior to
widespread approval and adoption, a situation that is rare in
prostate cancer. Experience shows that the uptake of
‘‘negative’’ trial evidence that stands in contrast to
prevailing opinion and subsequent attempts to deimple-
ment low value practices, are frequently hampered by an
uncritical passion for the new and advanced—referred to as
‘‘gizmo idolatry’’ . Rather than a continued escalation in
prostate cancer diagnostic and treatment complexity and
resulting costs we suggest a simple, safe, scientifically
sound solution as proposed by the IDEAL Collaboration in
which rigorous evaluation precede, not follow, wide-spread
new device implementation . When it comes to prostate
cancer detection, less intensive screening limited to well-
informed men aged 55–69 yr who inquire about the test are
in excellent health, performed no more frequently than
every 2 yr, and using higher PSA thresholds to define
abnormality is higher value; places the focus on individuals
most likely to benefit and least likely to be harmed while
reducing costs . For most men with PSA detected
tumors, especially those with low-risk disease, observation
or PSA-based monitoring is preferred. Aggressive[2_TD$DIFF], resource-
intense[3_TD$DIFF], and potentially harmful approaches should be
targeted towards younger, healthier men with higher risk
prostate cancer who are at greatest risk for succumbing to
their disease. The findings by Schroeck and colleagues
add valuable new information on our approach to prostate
cancer: radical interventions, especially newer more
expensive therapies, are unlikely to be higher value and
less treatment is likely to mean more health and lower cost.
Conflicts of interest: The authors have nothing to disclose.
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