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Introduction

  1. Top of page
  2. Introduction
  3. Conflict of Interest
  4. References

In a recent edition of the Journal of the American Medical Association (JAMA), Jacobs et al. [1] examined the important question of whether the use of advanced (read ‘expensive’) treatments, such as intensity modulated radiation therapy (IMRT) or robot-assisted radical prostatectomy (RARP), in elderly men with low-risk cancer is increasing. They retrospectively examined a USA cohort of men newly diagnosed with prostate cancer and captured in the Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Between 2004 and 2009, these men underwent IMRT (n = 23 633), external beam RT (n = 3926), RARP (n = 5881), open RP (n = 6123), or observation (n = 16 384). The chief finding of their analysis was that among men with low-risk disease, high-risk of non-cancer mortality, or both, the use of advanced treatment technologies has increased.

A review of their data shows that the rates of observation, RT and RP have remained stable overall from 2004–2009, at 29–29%, 50–48% and 21–23%, respectively. While there was an 11% increase in use of advanced technologies in men unlikely to benefit from treatment, this corresponded with an equivalent decrease in the use of traditional treatment methods, resulting in no significant rise in the overall rate of active treatment [1]. The relative use of IMRT increased from 65% to 96% in patients treated with RT and of RARP from 22% to 71% in patients treated with RP.

Jacobs et al. [1] speculate that direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of advanced treatment techniques for prostate cancer. There is reasonable evidence that direct-to-consumer advertising has played a role in the dissemination of RARP [2]. Yet, Jacobs et al. fail to mention that recent comparative effectiveness analyses have in fact shown the perioperative benefits of RARP over the open approach, even in elderly men [3, 4].

The extent to which fee-for-service incentives have driven the adoption of RARP is unclear, as there is little difference in reimbursement between RARP and conventional RP. In contrast, Medicare reimbursement is higher for RT (particularly IMRT) than for surgery, and the authors estimate that the increased use of IMRT translates into increased expenditures of $1.4 billion annually. This is associated, more importantly, with marginal or absent clinical benefit [5, 6]. While there is little evidence to suggest that direct-to-consumer marketing drives IMRT use, it is more difficult to dispute the role that financial incentives, e.g. ownership opportunities for referring urologists and fee-for-service reimbursement, may have played. If the incremental benefits of IMRT are minimal, it is important that this debate be continued. Although the rates of active treatment remain stable in men at low-risk of dying from prostate cancer, increasing use of IMRT will almost certainly accelerate the inflating costs associated with the treatment of localised prostate cancer in the USA.

References

  1. Top of page
  2. Introduction
  3. Conflict of Interest
  4. References
Abbreviations
(RA)RP

(robot-assisted) radical prostatectomy

(IM)RT

(intensity modulated) radiation therapy