A study suggests that the recent rapid uptake of intensity-modulated radiotherapy (IMRT) for prostate cancer in the USA has been driven by urologists with financial conflicts of interest.
Using Medicare insurance claims data, Jean Mitchell of Georgetown University, Washington, DC, found that an increased uptake of IMRT between 2005 and 2010 was seen only among urologists who referred patients to their own IMRT services. But, no such increase was observed among urologists who did not own such services.
“[T]his study shows that men treated by self-referring urologists, as compared with men treated by non–self-referring urologists, are much more likely to undergo IMRT, a treatment with a high reimbursement rate, rather than less expensive options, despite evidence that all treatments yield similar outcomes,” Mitchell writes.
Mitchell analyzed data on men treated for newly diagnosed, nonmetastatic prostate cancer at 35 private practices with established self-referral arrangements compared with 35 matched private practices without self-referral arrangements. Additionally, she compared the practices of urologists from 11 National Comprehensive Cancer Network (NCCN) centers who would be unlikely to derive financial benefit from particular services with those of urologists from 11 nearby self-referring private practices.
Among self-referring private practices, rates of IMRT referral rose from 13.1% in the pre-ownership period to 32.3% post-ownership, while rates of brachytherapy and androgen-deprivation therapy fell from 18.6% to 5.6%, and from 16.5% to 8.4%, respectively.
By contrast, the rates of IMRT referral in non–self-referring private practices remained unchanged over this period, at 14.3% and 15.6%. Rates of brachytherapy also remained unchanged among patients treated by these urologists, and there was a lesser decline in androgen-deprivation therapy use, from 15.6% to 11.4%.
Similarly, while IMRT use at the NCCN centers remained virtually unchanged over time, at around 8.0%, the rate of IMRT at the 11 matched self-referring private practices rose from 9.0% to 42.0% between the pre- and post-ownership time periods. This was accompanied by declines in the use of other therapies, including brachytherapy, androgen-deprivation therapy, active surveillance, and prostatectomy.
Writing in the New England Journal of Medicine, Mitchell says the findings suggest that allowing urologists to self-refer for IMRT has contributed to the increased use of the therapy in spite of evidence suggesting it is no more effective than alternatives.
She adds that this is of particular concern among older patients, “for whom the risks of undergoing intensive irradiation probably exceed the benefits.”
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