Differences in treatment choices for localised prostate cancer diagnosed in private and public health services

To the Editor: Te Marvelde and colleagues1 report that patients with prostate cancer diagnosed in the private health system in Victoria are more likely to undergo radical treatment than patients in the public system. In particular, they report that patients in the private system undergo surgery more often than those in the public system (44% v 28%; odds ratio, 2.28; 95% CI, 2.13–2.44). The authors do not provide an explanation for this, but the inference is that private patients may be more likely to be overtreated in private hospitals. We respectfully point out two more plausible explanations.

First, prostate‐specific antigen (PSA), local clinical staging, and cancer grading form the three essential parameters that define the risk groupings of low, intermediate and high risk prostate cancer. This risk categorisation forms the basis upon which evidence‐based clinical guidelines recommend treatment options, which unfortunately has not been accounted for in the article by te Marvelde et al. The suggestion that cancer grade alone is sufficient to inform on treatment choice is without evidence and is a limitation of this article. Much more granular risk stratification is already available to describe patterns of care of prostate cancer in Victoria from the Prostate Cancer Outcomes Registry (PCOR‐Vic), and these data have already reported that patients diagnosed in the private system in Victoria are actually less likely to undergo treatment than those diagnosed in the public system.2 The PCOR‐Vic data are in direct contradiction to this article, but are more robust as they are based on a granular registry across both public and private health systems, with many publications to validate patterns of care in Victoria.3,4,5

Second, patients in the public system are much less likely to access minimally invasive surgery than patients in the private system, which is likely also a deterrent to surgery in the public system. In 2019, 88% of prostatectomies performed in the private sector were performed using a robotic approach, compared with only 28% in the public sector.6 This ongoing inequity likely leads to underutilisation of surgery for patients in the public system.

There is also a failure to contextualise major studies mentioned in the discussion to support the authors’ interpretation of their data. For example, the ProTect study is cited to highlight the lack of differences between treatment options for prostate cancer. This study was conceived and commenced well before active surveillance became accepted as the most appropriate treatment for low risk prostate cancer, where 77% of participants were categorised as such. Rates of utilisation of active surveillance in Australia, including in the private sector, are among the highest in the world and are not accounted for by the authors. In addition, the reference to 40% of overdiagnosis rates based on data collected from 1982 to 2012 bears no reflection on current practice.7 Te Marvelde and colleagues have also failed to consider the recent evidence that magnetic resonance imaging reduces the rates of overdiagnosis of low risk prostate cancer while improving the detection of clinically significant cancers.8

The authors assert that treatment of people with cancer should be high quality and evidence‐based. Nobody would disagree with this. Indeed, let us cite high quality randomised controlled trials to support the interpretation of the data we publish, but appropriate contextualisation is everything.