Active Surveillance ~ Is it becoming too complicated?

Interesting timing given Akai's thread on insurance coverage for an MRI while he is on active surveillance.

Here's an interesting discussion from the Infolink and from two noted PCa authorities Klotz and Sartor.

prostatecancerinfolink.net/2013/06/12/how-active-should-active-surveillance-really-be-are-we-being-overly-cautious/

The question raised in Akai's thread was insurance refusing an imaging scan while he was on AS. This is a real problem for the financial aspect of AS. Are we over watching this disease if we start sending every newly diagnosed man to do an MRI, even if his data looks quite indolent? Will this become the new problem after screening produces a large number of AS patients in the future.

This is part of the ODOT discussion so I hope all can discuss peacefully. But if this becomes a big problem it will further exacerbate the problematic pro-screening discussion.

So far there is some push back from insurance carriers which would prefer to just go right to treatment rather than a complicated and expensive AS program. Stay tuned on this one.

If I were a man considering AS, I would ask if such imaging was absolutely necessary. And if no consensus could be reached I would probably advocate to get the scan. But the scientific evidence on imaging scans and AS is just about nonexistent and probably decades away. Right now it appears to be a "feel good" move rather then a practical one. (IMHO)

Tony

Bob,
The ACA eliminates the pre-existing conditions clauses but that does not mean that they can't adjust their charges for it. So while pre-existing won't be a problem moving forward, incurring charges that cannot be proven to be shown as absolutely necessary can be a problem for any and all men on AS and the carriers CAN in fact stick to the need for proof that it is necessary.

Tony

http://prostate-cancer.org/color-doppler-and-tissue-harmonic-ultrasound-in-the-early-detection-and-staging-of-prostate-cancer/[url]

This is an interesting article by Dr Bahn in using CDU to biopsy and what he looks for before doing a biopsy. As he states and I can confirm is that a CDU is much more accurate than an MRI in identifying anterior or transition zone tumors because of the difference in tissue harmonics of the TZ from the PZ. I also believe that CDU is also less expensive than an MRI and it is easier to do a targeted biopsy with a CDU.
JT

TC-LasVegas said...
Interesting timing given Akai's thread on insurance coverage for an MRI while he is on active surveillance.

Here's an interesting discussion from the Infolink and from two noted PCa authorities Klotz and Sartor.

[url]http://prostatecancerinfolink.net/2013/06/12/how-active-should-active-surveillance-really-be-are-we-being-overly-cautious/[/url

The question raised in Akai's thread was insurance refusing an imaging scan while he was on AS. This is a real problem for the financial aspect of AS. Are we over watching this disease if we start sending every newly diagnosed man to do an MRI, even if his data looks quite indolent? Will this become the new problem after screening produces a large number of AS patients in the future.

This is part of the ODOT discussion so I hope all can discuss peacefully. But if this becomes a big problem it will further exacerbate the problematic pro-screening discussion.

So far there is some push back from insurance carriers which would prefer to just go right to treatment rather than a complicated and expensive AS program. Stay tuned on this one.

If I were a man considering AS, I would ask if such imaging was absolutely necessary. And if no consensus could be reached I would probably advocate to get the scan. But the scientific evidence on imaging scans and AS is just about nonexistent and probably decades away. Right now it appears to be a "feel good" move rather then a practical one. (IMHO)

Tony

Tony:
I do not believe that it is that complicated, my Uro does not have a standard protocol, unlike most other formal programs, though we follow PSA test every three months, DRE and Color Doppler Ultrsound every six months. NO schedule for repeat biopsy on an annual basis, this is why we were thinking about using MRI to help determine if BX is necessary. The lack of an ability to predict whether my PCa is indolent or aggressive is what led to trying to use any and all tools to prevent an unnecessary Bx. Most other programs required an annual Bx (especially the first anniversary). My Uro could have just chosen to perform a Bx and be done with it. The fact that my PSA is stable and below 4.0 is perhaps not as worrisome. Is the pmMRI a good screening tool, I do not know. I have read come across couple of studies from UK and France that seem to think that MRI has a role in AS, you can google "MRI in Active Surveillance" to find the two studies that I mentioned.

Post Edited (akai) : 6/12/2013 4:55:54 PM (GMT-6)

I'll do some reading about ACA so I'm better informed. Based on what was posted above and what I have read elsewhere, my current understanding is they can't deny a person coverage because of a pre-existing condition but they can adjust your premium if you do have a pre-existing condition. If that's true, knowing the way insurance companies work a person is going to pay one way or another.

I know I'm going off on a tangent but... What about someone like me who had the surgery, removed the cancer, and now has an undetectable PSA. Do I still have a pre-existing condition? Statistically at this point I think the average Joe (that still has his prostate) is more likely to get prostate cancer than I am right now.

Tony,
You are absolutely correct in that CDU requires a great amount of skill that only a few doctors possess. The newer machines that use a much more powerful ultrasound in combination with the color doppler are much more effective than the older machines that most of the studies were conducted on, regardless, the skill level of the operator is the limiting factor in their usefulness. There are probably only 5 or 6 doctors with the skill level to detect small cancers.
As they say in radiology, "it's not the arrow, it's the Indian".
Regarding Dr Bahn, I also heard he is no longer taking medicare. Personally I would pay out of pocket for his services, because I think he is that good in what he does. It took 12 biopsies and 150 cores to find nothing. He found 3 of 3 cores the first time, so for me it was less expensive, because it was done right the first time in one visit. I probably had at least 40 to 60 doctor's visits before that. I've always found it cost effective to do something right the first time even at a higher initial cost. I'm a firm believer in finding the best doctor you can, especially when your life depends on it; I'll skimp on other things to pay for it.

The insurance and Medicare is clear cut. Between COBRA and PPACA insurance coverage will be there for you as will Medicare at age 65. No qualification....no preexisting....no additional costs for coverage.

However that you have insurance and/or Medicare doesn't mean that any and every procedure will be reimbursed. PPACA does little for that other than providing for contraceptives that most of us do not need. Any procedure that your insurance or Medicare does not reimburse is still available to you so long as you decide to pay for it. If a doctor says they don't accept insurance or Medicare, it doesn't mean you are naked. It means that you must file the claim and get the amount of reimbursement that your coverage or Medicare pays for the procedure. Caveat emptor.

I don't know much about AS as it was certainly not an option for me. But why is it so complicated? For most men a careful system of monitoring PSA every three months or so should tell a lot. By definition, AS is limited to those who are very low risk to begin....low PSA, low Gleason....and very little tumor load. While all the leading edge scans are of interest, I question their practicality in the early stages. Are we trying to complicate somethiong that isn't complicated? And if one is in question as to whether they should pursue AS due to risk factors....why not just pursue the least invasive treatment option which is well proven for effectiveness in low risk scenarios?

And at the end of the day if there are procedures you want that aren't reimbursed by insurance or Medicare, then just pay for it. If you hesitate to pay from your own money, why expect the third party to pay??

Have to be truthful....Ive yet to have an issue with Tricare yet.....they've covered everything for me so far......the only issue I had was I was denied a Pet scan and had to do the regular bone scan but that one worked just fine for verifying my bone mets. So far Ive been able to pick the drs I wanted to go with but Ive also tried to stay as local as possible or within a 2 hour drive.

JNF

And at the end of the day if there are procedures you want that aren't reimbursed by insurance or Medicare, then just pay for it. If you hesitate to pay from your own money, why expect the third party to pay??

One of the reasons I expected my insurance to pay for a procedure that my doctor prescribed is because they take $2,850 from me/my employer every month. Yes I could have paid for it myself, but why should I? This is not an elective cosmetic surgery (pmMRI).

I think simple quarterly or biannual PSA testing would certainly be enough for most guys on AS. But here's my list of qualifications:

• If you don't have prostatitis that will confound the PSA results
  
• If you don't have BPH that will confound the PSA results, or if you do, (and most guys old enough for PCa are old enough for BPH too) you have stabilized your PSA with Avodart or Proscar and have established a new baseline PSA that is more sensitive to PCa.
  
• If you have a variety of PCa that produces PSA in relation to the size and grade of the tumor.
  
• If you were truly Gleason 6 to begin with
  
• If you were diagnosed with very low risk PCa (=low risk + one or two positive cores + <half of any core positive + <.15 PSA density) or if your life expectancy is less than 10 years.
  

These are a lot of ifs and I don't think even a majority of men on AS would meet all of those qualifications.

I don't know that an mpMRI or CDUS is needed every year or that a biopsy (image-guided or saturation) is needed every year. If I don't meet the above qualifications, I would want one at around the first year anniversary at the least -- as many as 40% of Gleason scores get upgraded at pathology -- it seems a double-check is prudent. After that, I'd want to make decisions based on the trends - does something seem to be growing or is it stable? If it's insignificant in volume and stable, I might feel comfortable waiting another 5 years for another imaging study or biopsy. If it seems to be bigger, I may want to repeat the next year. There is no one-size-fits-all protocol, and I doubt that there ever will be.