Upfront

Welcome to PSA Rising.  We have some good news and bad news. The good news is that the U. S. Government has increased money to the National Institutes of Health by $2 billion, or 15 per cent, and has urged N.I. H. "to make prostate cancer a top priority" and to "accelerate spending" on the disease. A qualifier to this (reported by Robert Pear in the New York Times, Nov. 1) is that after the Senate Appropriations Committee chaired by Sen. Ted Stevens (R. Alaska) earmarked $175 million for prostate cancer research, House and Senate negotiators dropped that specific amount.
    If that means losing some pie-in-the-sky, our bad news hits close to home with a jab in the belly: Medicare plans to withhold full payment from prostate cancer patients on Medicare who are taking Lupron.
    Medicare wants to pay only the cost of Zoladex, which is cheaper than Lupron by around $125 per month. Medicare is doing this as a step in extending its "Least Costly Alternative" policy to prescription drugs. Some states have already lost this battle. In 6 states (California, Arizona, Arkansas, Nevada, Oregon, Hawaii), you have a brief window of opportunity right now to comment.
    Write to people on the Contacts page. In California write above all to:
Arthur Lurvey
Medical Director Transamerica
Occidental Life Insurance
1150 South Olive Street
Los Angeles, CA 90015-2211
[email protected]

Patients Need Choice
Lupron and Zoladex, two luteinizing hormone-releasing hormone (LHRH) analogues, block testicular production of testosterone. Although Lupron costs more than Zoladex, many patients on the advice of their doctors choose Lupron.
    Some find Lupron's side-effect profile easier to tolerate; many find the injection method less onerous. Lupron is injected into muscle in the buttock with a 23-gauge needle. Zoladex is injected subcutaneously into the upper abdominal wall with a much larger, 16-gauge needle.
    Today, patients with early disease are often advised to take an LHRH analogue for months before surgery or radiation. Some men take these drugs intermittently. Patients with progressive metastatic prostate cancer normally stay on LHRH agonists until the end of life. Scores of thousands of men on these drugs are frail, fatigued, and in severe, debilitating pain because of metastases to bone. Many are fighting anxiety and depression. Forcing prostate cancer patients to switch to a rival drug with the disadvantage of injection to the belly with a needle the size of a toothpick is highly likely to harm the patients' quality of life.
    Paying no attention to pain, discomfort and normal desire for control and choice, Medicare's carriers say that "there is no medical reason" for choosing the Lupron "delivery system" over that of Zoladex. This is an insult to patients. And if you look at their own clinical references, we believe you'll see that it's intellectually dishonest.
    "Although we acknowledge that the differences in administration methods may cause a preference ..." says California Medicare carrier TransAmerica Occidental Life, "clinical evidence and FDA indications do not support differential effectiveness of one over the other for prostate cancer treatment. Therefore ... Medicare will only pay for the dosage administered for either of these drugs at the rate approved for the lower priced of the two."
    In 1992 a team of researchers called the Zoladex Prostate Cancer Study Groupreported on work with patients who had advanced prostate cancer. These researchers compared surgical castration with the newer, chemical method. Doctors had known for decades that shutting down testosterone may temporarily halt advanced prostate cancer, relieving urinary obstruction and bone pain. Evidence was coming in showing that LHRH agonists do this as effectively as surgical castration (orchiectomy) and more safely than by dosing men with the female hormone estrogen.
    But were there medical reasons (they asked) for preferring monthly injections over surgical castration? Surgical castration (as Australia calculated) is much cheaper than hormonal. Why not keep using the scalpel?
    Why not? Because men don't like being surgically, irreversibly castrated. That's part of what the 1992 Zoladex Prostate Cancer Study Group found by asking patients about their quality of life.
    That 1992 study was "among the first to evaluate patients' appraisals of their lives following treatment choices for advanced prostatic cancer." The outcome spoke "compellingly," the researchers said, "for including quality of life in assessments of therapy."
    Today, Medicare's California carrier lists that 1992 patient-centered study as evidence for denying prostate cancer patients the very type of choice which that study showed was medically justified. Too bad nobody has ever asked patients if they prefer Lupron injected in the buttock with a moderately large needle to Zoladex injected in the belly with a whopper of a needle.
    Medicare and the insurance carriers are deploying a skimpy veneer of patient-centered medicine while making cost an excuse for chiseling at the cancer patients' need and right to choose treatment on the advice of doctors.
    Why are they pushing this at this time of "accelerated spending" on prostate cancer? Are the insurance carriers afraid of seeing pie-in-the- sky turn at last into really improved treatment for this shamefully neglected disease, and a cure? In view of the priority which the House and Senate put on prostate cancer, Medicare has no political mandate for targeting men on hormonal therapy. We must speak out.