HA: Overuse strikes again? IMRT skyrockets for prostate cancer

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Despite conflicting reviews about its clinical benefits, cost-effectiveness and additional costs up to $20,000 more per treatment, intensity-modulated radiation therapy (IMRT) use increased more than tenfold among Medicare beneficiaries with prostate cancer from 2001 to 2007, according to a study published in the April issue of Health Affairs. The findings may suggest overuse and could foreshadow a similar challenge with the adoption of proton beam therapy. The authors suggested several policies which might help bend the cost curve.

Prostate cancer is diagnosed in more than 200,000 men annually in the U.S. and accounts for more than $7 billion in healthcare spending each year. Its average annual spending growth rate of 11 percent exceeds other common diseases. “This is due, at least in part, to the introduction of novel, expensive technologies,” wrote Bruce L. Jacobs, MD, a fellow in urologic oncology, endourology and health services research at the University of Michigan in Ann Arbor, and colleagues.

Jacobs and colleagues cited IMRT as a prime culprit in the spending spree. They noted limited evidence supporting IMRT in terms of cancer control and quality of life outcomes and high-level evidence supporting 3D conformal therapy.

The researchers designed an analysis to better understand IMRT adoption and compare use of IMRT with 3D conformal therapy. They mined Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data to identify 19,846 men treated with IMRT and 16,644 men treated with 3D conformal therapy between 20001 and 2007. All patients were age 66 or older.

Men with well-differentiated tumors, regardless of age, or those with moderately differentiated tumors and age 65 or older at the time of diagnosis were classified as low risk. All other patients were categorized as having high-risk prostate cancer.

During the study period, the rate of 3D conformal therapy dropped nearly 90 percent, Jacobs et al reported. IMRT use increased from approximately 220 cases per 10,000 Medical beneficiaries diagnosed with prostate cancer to more than 2,800 cases per 10,000 in this population.

The researchers noted the rapid adoption of IMRT among patients with both low-risk and high-risk disease. Initially, from 2001 to 2003, adoption was more likely among men with high-risk disease. However, after the initial dissemination period, men with low-risk and high-risk disease had fairly similar likelihoods of receiving IMRT, according to Jacobs et al.

“Reasons underlying IMRT’s rapid adoption are likely to be complex and multifactorial,” they wrote. Although the treatment may provide better cancer control and lower morbidity, the fairly even rates of use among low-risk and high-risk patients seem “to dampen this argument.”

Competitive and economic factors, including Medicare reimbursement of $14,000 more per patient than 3D conformal therapy, may have fueled uptake.

Physician-owned IMRT-treatment facilities also are exempt from the Stark Law, so “some physicians may view IMRT as an investment opportunity.” IMRT start-up costs can reach $2 million, which could lead to financial pressures to treat marginal patients, according to the researchers.

The issue, wrote Jacobs and colleagues, is the price society is willing to pay for small incremental benefits in outcome from a more costly technology. IMRT is the tip of iceberg, they wrote. Proton beam therapy, which has a price tag exceeding $100 million per facility, is another new treatment with “hypothetical improvements.”

Jacobs and colleagues suggested four initiatives may stem the tide of unsustainable technology adoption. These are:

  • Accountable care organizations, which may mitigate the fee-for-service incentive for physicians to do more;
  • Bundled payments and prior authorization initiatives to discourage less efficient or inappropriate resource use;
  • Development and application of comparative effectiveness research; and
  • Coverage with evidence development to generate data about evidence and effectiveness.

“Paying for what works, even if it does not incorporate the newest, most expensive treatments with all the ‘bells and whistles,’ will serve us best as we attempt to expand healthcare coverage and limit overall spending,” concluded Jacobs et al.