The American Society for Radiation Oncology (ASTRO) has issued the following statement in response to the study “Growth of high-cost intensity-modulated radiotherapy for prostate cancer raises concerns about overuse” published in Health Affairs.

In a recent Health Affairs study, researchers explored the rise in intensity modulated radiotherapy (IMRT) for prostate cancer use from 2001 – 2007. IMRT is quickly becoming a standard treatment for prostate cancer patients. It delivers high doses of radiation to the tumour, providing better cure rates and lower chance of recurrence, and reduces the amount of radiation delivered to surrounding tissues, reducing the risk of side-effects.

The authors said “IMRT would represent a major therapeutic advance for men with prostate cancer.” ASTRO agrees, and our position is supported by a study published last month using SEER data from 2000-2009 for prostate patients showing that IMRT improves cancer control, significantly reduces toxicity to the rectum and reduces the risk of hip fractures.

We agree with the authors’ call for more data and for more patients to participate in research, such as clinical trials and registries. The Radiation Oncology Institute is currently developing the infrastructure for a registry to collect and analyse data, with the initial pilot project focused on prostate cancer. More than 75 centers have applied to participate in the pilot, which is expected to launch later this year.

The authors make a strong point addressing self-referral abuses in the use of IMRT for prostate cancer patients. IMRT reimbursements are higher than traditional radiation therapy because it is more complex and requires significant quality assurance to deliver it safely and effectively. However, because of the necessary high reimbursement rates, urology-owned radiation therapy centers have proliferated across the country.

Nearly one in five urology practices now own IMRT machines, according a recent survey in Urology Times. The expansion of these mega-urology practices can dominate prostate cancer diagnosis and treatment services in their market areas and likely played a role in the growth of IMRT use during the study period.

The authors cite marketing materials by Urorad Healthcare, a for-profit company based in McAllen, Texas, that has “aggressively marketed IMRT to urologists, claiming that treating 1.5 new patients monthly with IMRT could generate more than $425,000 in additional revenue per physician each year.” That certainly sounds like putting profits before patients.

In addition to recent The Wall Street Journal, The Washington Post, and The Baltimore Sun reports exposing self-referral abuse in urologists’ use of IMRT, national studies are underway. ASTRO is supporting a Georgetown University independent analysis of the effect of physician self-referral on urologists’ use of IMRT for prostate cancer patients. Also, at ASTRO’s request, Congress asked the Government Accountability Office to investigate the clinical and economic impact of physician self-referral on urologists’ IMRT use. We expect these analyses will shine light on how physician self-referral is significantly contributing to overuse of IMRT, similar to the impact on anatomic pathology services revealed in the April issue of Health Affairs.

IMRT yields benefits to prostate cancer patients through increased tumour control and fewer side effects, which will ultimately reduce health care spending on prostate cancer and demonstrate the value of IMRT. At the same time, all patients may not be ideal candidates for IMRT and patients should be presented with all of their options, including active surveillance. The problem identified by the authors is not caused by the reimbursement rate of IMRT, which has declined by about 30 percent over the last six years, but rather its overuse on patients who don’t need it.

ASTRO respects and appreciates the thorough scholarship of these leading academic researchers in recognising the clinical advances associated with IMRT and abuses associated with physician self-referral. We will continue to work with Congress to close the self-referral loophole that leads to this abuse and ensure all cancer patients receive the safest, most cost-effective cancer treatments.

Source: ASTRO