The past few weeks have had me thinking: can Americans adapt to a message in medicine that "less is more," when science confirms it?

Back in April, at the American Urological Association (AUA) annual meeting, the AUA issued its first-ever guideline for the treatment of early-stage kidney cancer. It is actually good news for patients.

The guideline states that the kidney should be saved whenever possible. Complete removal of the kidney [in early-stage kidney cancer]"puts patients at risk for chronic kidney disease and cardiovascular disease," according to the AUA.

In recent years, the number of people diagnosed with early-stage kidney cancer who had their kidneys removed rose dramatically. Many were diagnosed when they had no symptoms and only had their cancers identified through an imaging study done for another reason. Many people thought that they were doing well because the kidney was totally removed, when the cancer was confined to a relatively small part of the kidney.

AUA's specific recommendations for early-stage kidney cancer state that any of the following are reasonable treatment options:

• partial removal of the kidney
• thermal ablation, which uses heat to remove cancerous tissue
• active surveillance

According to the AUA, these treatments "minimize risks and are viable options for patients with early-stage kidney cancer."

Does the average patient with early-stage kidney cancer know of these new guidelines? Do urology oncologists treating kidney cancer follow these guidelines? It is probably much too soon to tell.

Taken in the context of the conflicts in the past few weeks over recommendations for less PSA screening, less breast cancer screening, and less cervical cancer screening, I commend the AUA and other physician organizations for reviewing the balance of benefits and harms in treating early-stage kidney cancer more aggressively.

I remember all too well the ruckus that ensued after a landmark clinical trial revealed that a lumpectomy resulted in no compromise in cancer control, yet spared the breast of women with early-stage breast cancer.

I think that it is going to take awhile for the American public to get used to thinking that less imaging, less screening, and less treatment in certain cases could possibly be better than more. Even though it has been a rocky start, we are taking some very positive steps.

Related Links

_{Guideline for the Management of the Clinical Stage I Renal Mass American Urological Association, 2009.}

American Cancer Society. Detailed guide. What are the key statistics for kidney cancer? American Cancer Society, 2009.

If you set up a flexible spending account with your employer in 2009, now is the time to review whether you have spent the money that you set aside. A flexible spending account (FSA) is an employer-sponsored benefit that you set up at the beginning of each year for spending on health care needs using pre-tax dollars.

Useful for some, flexible spending accounts may be moot for people who spent 2009 unemployed and for those who did not have extra dollars to divert to an FSA. FSAs are not available to those on Medicare.

FSAs allow you to purchase items that can be extremely costly when paid for out-of-pocket:

• Continence and toileting supplies, including adult diapers
• Fees for hospital services, long-term care services, accident and health, and qualified long-term care insurance premiums, nursing services, laboratory fees, prescription medicines, and insulin
• Medical equipment (walkers, shower curtains, wheelchairs, etc.)
• Gloves, first aid supplies, bandages, etc.

If you are still running short on spending your FSA allowance, consider adding these items:

• Hand sanitizer. Because of the H1N1 (swine flu) virus, this is now an allowable expense.
• Cold and flu medication
• Contact lenses, eyeglasses, hearing aid batteries.
• Sunscreen

Keep in mind that these benefits usually do not roll over. In some instances, an employer will allow you to carry your benefits forward, but you should check with your employer as soon as possible.

Have people found having that an FSA helps them manage their health care expenses?

Now is the time to actively review your options for Medicare Part D enrollment for 2010. You have until Dec. 31, 2009 to complete Medicare Part D enrollment, but health advocates suggest you review your plan options early and decide by Dec. 6th. Following the path of least resistance--rolling over into your current plan for next year, may not be cost effective and offer quality care. This is the once-a-year Medicare enrollment period.

To help you along, advocacy groups around the country are making themselves available to seniors:

• Note to New York City Seniors: New York State Assemblymember Linda B. Rosenthal invites you to attend a Medicare Open Enrollment Information Session with the Medicare Rights Center tomorrow, Tuesday, Nov. 17, 2009, from 1PM to 2PM at JASA, 120 West 76 Street, between Columbus and Amsterdam Avenue. All are welcome. Light refreshments will be served.

Also check with State Health Insurance Assistance Program, a national program that offers one-on-one counseling and assistance to people with Medicare and their families. Through federal grants directed to states, SHIPs provide free counseling and assistance via telephone and face-to-face interactive sessions, public education presentations and programs, and media activities.

Picking the right plan is especially important for people who have significant health problems, whose health costs could spiral out of control, and those who hit the doughnut hole last year.

It will also be something you should review in the event of unexpected health problems in 2010.

How much risk are you comfortable taking on?

For the Medicare population with specific urology problems, take a hard look at how plans compare on drug and treatment coverage for urologic cancers, such as prostate, kidney, and bladder cancer, and an enlarged prostate or incontinence. I hope to provide you with more detailed suggestions on getting through this process as easily as possible.

Low-risk cancer is the diagnosis for 7 of 10 men diagnosed with prostate cancer, and if all 10 men chose radiation therapy for prostate cancer treatment, only 3 men would need hormonal therapy before and during radiation therapy.

That's the take-home message from the National Cancer Institute's Radiation Therapy Oncology Group trial 94-08, the largest and longest trial of what is known as neoadjuvant hormonal therapy, hormonal therapy given to shrink the tumor prior to and during radiation therapy, Anthony L. Zietman, MD, president of the American Society of Therapeutic Radiation Oncology (ASTRO), told About.com's Urology Guide. Results from the trial were highlighted at the recent annual ASTRO meeting, the largest worldwide meeting of physicians involved in therapeutic radiation oncology.

Men who do not gain any benefit from hormonal therapy (the 7/10) are low-risk patients, which Dr. Zietman defined as men having PSAs between 4 and 5 and low-grade cancers, measured by a Gleason score 6 or lower. "Where it is clearly helpful is in men with intermediate- and high-risk cancers," he added.

If you have been diagnosed with prostate cancer, you should review these figures on your lab sheets and discuss this with your doctor.

Hormonal therapy was extremely popular, heavily promoted by industry, and lucrative for physicians during the 1990s. It caught on like wildfire across the United States, even though the evidence for using it was controversial.

What this really signals is another example of overuse of medical care that is not beneficial and may cause harm. It may sound discordant with how Americans view medical care.

However, Dr. Zietman explained: "Getting more from less fits with what patients really want and with contemporary economic reality." He added: "Recognizing areas of medicine in which we have been overtreating and changing our practice is what I call conscience-based medicine. It means doing what is right, whether it is ensuring that our patients get more when more is needed, or less when less is best, not operating with our wallets."