Advanced treatments common in low-risk prostate cancer patients

The use of advanced treatments-namely, intensity-modulated radiation therapy (IMRT) and robotic prostatectomy-in patients with low-risk prostate cancer has increased significantly, despite little evidence of benefit, according to a recently published study from the University of Michigan Comprehensive Cancer Center, Ann Arbor.

In a statement that quickly followed the study’s publication, the American Society of Radiation Oncology (ASTRO) said its findings provide further proof of abuses in physician self-referral.

Study authors examined Medicare data between 2004 and 2009 for men with prostate cancer whose disease was low risk or those who were at a high risk to die from other causes. The researchers found that these men increasingly underwent advanced treatment options such as IMRT and robotic prostatectomy.

Among men with low-risk disease, the use of advanced treatments increased from 32% to 44%, the study found. Similarly, in men with a high risk of non-cancer mortality, the use of these treatments increased from 36% to 57%.

The results of the study, which were published online in JAMA (June 25, 2013), suggest that potential overtreatment of prostate cancer is increasing even at a time of greater awareness about the sometimes indolent nature of the disease, said senior author Brent Hollenbeck, MD, MS.

"Not only do these procedures offer very limited benefits to this group of patients in terms of survival, they also are significantly more expensive than prior treatment options, amplifying the economic implications of potential overtreatment,” Dr. Hollenbeck said.

Dr. Hollenbeck said there are several dynamics that might explain the findings. Patients and physicians are sometimes hesitant to embark on an observational treatment plan when an advanced procedure may cure the disease, he said. Additionally, the stress and anxiety of living with cancer can be overwhelming for some patients.

"While those concerns are valid, the outcomes of men with low-risk disease who follow an observational management plan as opposed to procedural treatment are well established," Dr. Hollenbeck said. "In addition, the financial incentives to do these procedures, through things like fee-for-service reimbursement, may simply be too strong to overcome."

More research and policy changes are needed in order to shift the current treatment patterns for men at low risk of dying from their prostate cancer, he said.

In the ASTRO statement, Chairman Michael Steinberg, MD, said the study “reaffirms the Society’s commitment to closing the self-referral loophole for radiation therapy within the Ethics in Patient Referrals Act.”

“ASTRO supports the use of IMRT as an appropriate, effective treatment for prostate cancer patients; however, IMRT should be carefully considered along with other effective treatments and management options, including active surveillance, by patients and their doctors,” the statement said. “Treatment decisions should not be based on the physician's potential for profit, yet we believe profit-motivated IMRT overuse is rampant due to the proliferation of urology ownership of radiation therapy centers.

“We agree with [the study authors’] concerns that financial incentives may be negatively impacting treatment decisions, which we believe are compounded by ownership arrangements protected under the self-referral loophole.”

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