Mark Brandt and his wife Linda used their savings to pay his out-of-pocket health costs. "While a few thousand dollars may seem not so bad for someone earning the salary of a surgeon, if you're a person who is just making it week to week, it's a lot of money," Professor Aranda said. "And when a cancer diagnosis means you're out of work and if you don't have enough sick leave, it really can tip people into poverty," she said. "It's an extremely difficult time for patients. You start to build a relationship very quickly with your surgeon and you put your trust in them. Looking for alternatives takes extra time, which is very confronting for someone with a cancer diagnosis." Another tactic was to tell people they'd face long waiting lists in the public system to convince them to go private.

Chief executive of Cancer Council Australia Professor Sanchia Aranda warned of "financial toxicity" in the health sector. But cancer patients were prioritised in the public sector, meaning the waiting times were no different for public versus private patients, Professor Aranda said. Mark Brandt, 53, was diagnosed with prostate cancer last year. His surgeon was a constant figure throughout the weeks of anxiety as he waited for a definitive diagnosis. Mark Brandt was told robotic surgery, costing $14,000, was his best chance of survival. "There's a lot of emotion involved, and you go through all this with one person looking after you," he said.

The father of four was told robotic surgery was his best chance of survival. "[My surgeon] said 'we are going to book you in for the operation. Go see the practice nurse manager outside.' "We go out and she hands me a piece of paper: $14,000 in out-of-pocket costs for the procedure," he said. Mr Brandt said he and his wife Linda asked what would happen if they switched to the public system. They were told the waiting times were huge. "So many things are running through your head," he said. "By that stage you're so far down the track you don't want to start looking for alternatives. You're exhausted."

The surgery and the cost of follow-up care ate through the couple's savings. Mrs Brandt: "There's not much change left from $20,000 ... we can't gain access to super to pay the medical bill, we can't retire, we can't get an aged pension or a disability pension because he's not terminal, and we're still going to some sort of doctor's appointment almost every week." Professor Aranda co-authored an editorial in the MJA with Professor David Currow, CEO of the Cancer Institute NSW published Monday, addressing this type of "financial toxicity" influencing patient's treatment outcomes. Prostate cancer patients were a classic example because the treatment pathway dictated their first referral was to a surgeon, who might not necessarily inform them that radiotherapy was an appropriate alternative, she said. "Patients can also find themselves caught out by additional costs because a surgeon only has to disclose what their fee would be, not the costs of anaesthetics, pathology, hospital stays, and over 12 months of cancer care," she said.

Urologist and professor of surgery at the University of Sydney Henry Woo believed narcissism among some surgeons was the underlying reason doctors engaged in these practices. "Some surgeons have a self belief that only they can provide the highest quality of care to patients," said Professor Woo, who performs prostate surgery at the Sydney Adventist Hospital. "They'll tell patients they're the best, or they've performed the most procedures and vulnerable patients easily fall for this type of marketing. "I get particularly upset when patients who do not have insurance are goaded into paying for private surgery when their surgeon could quite easily have referred to have their surgery performed with excellent care in the public system," he said. He said patients needed to be made aware there was no cancer surgery in private hospitals that could not be done in the public hospital system, referring to robotic prostate surgery at Nepean Hospital in Penrith. "Hopefully addressing this will prick the conscience of surgeons that feel justified in charging exorbitant rates in surgical services."

President of the Urological Society of Australia and New Zealand Mark Frydenberg said no patient should be placed under financial stress by excessive surgical fees. "There is no evidence that the fee charged equates to better quality of treatment, care or surgical outcomes," Professor Frydenberg said in a statement. "[The society] expects members to uphold the highest ethical standards when charging for their services and to also provide full disclosure of all anticipated out-of-pocket costs as early as possible," he said. "It would be extremely disappointing if the actions of a few risked tarnishing the reputation of all urological surgeons who typically maintain the highest ethical and professional standards of care and concern for the wellbeing of their patients."