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Advanced treatments increased among prostate cancer patients least likely to benefit
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The use of advanced treatment technologies, including intensity-modulated radiation therapy and robotic prostatectomy, has increased among patients with prostate cancer who exhibited low-risk disease and those who were least likely to benefit from treatment, according to study results.
“Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced treatment technologies,” Bruce L. Jacobs, MD, MPH, of the department of urology at the University of Michigan, and colleagues wrote. “[However] the extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain.”
Bruce L. Jacobs
To determine the use of advanced treatment technologies among men with a low risk of dying from prostate cancer, Jacobs and colleagues used SEER–Medicare data to identify patients with newly diagnosed disease between 2004 and 2009.
The cohort included men who underwent IMRT (n=23,633), external beam radiation treatment (n=3,926), robotic prostatectomy (n=5881), open radical prostatectomy (n=6,123) or observation (n=16,384). Follow-up data were available through Dec. 31, 2010.
Jacobs and colleagues defined low-risk disease as clinical stage ≤T2a, biopsy Gleason score ≤6 and PSA level ≤10 ng/mL. They defined high risk of noncancer mortality as the predicted probability of death within 10 years in the absence of a cancer diagnosis.
During the study period, the use of advanced treatment technologies increased from 32% to 44% among men with low-risk disease (P<.001) and from 36% to 57% among men with high risk of noncancer mortality (P<.001), the researchers reported.
In addition, the use of advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% to 34% (P<.001).
“The most common treatment modality was IMRT, which accounted for the greatest use among men who stand the least to gain in terms of survival,” Jacobs and colleagues wrote. “The increasing use of both IMRT and robotic prostatectomy in populations unlikely to benefit from treatment was largely explained by their substitution for the treatments they aim to replace, namely [external beam radiation treatment] and open radical prostatectomy.”
Among all patients diagnosed in SEER, the researchers observed that the use of advanced treatment technologies for men unlikely to die of prostate cancer increased from 13% to 24% during the study period.
“The implementation of these technologies in populations unlikely to benefit from treatment occurred during a time of increasing awareness about the indolent nature of some prostate cancers and of growing dialogue about limiting treatment in these patients,” Jacobs and colleagues wrote. “Continued efforts to differentiate indolent from aggressive disease and to improve the prediction of patient life expectancy may help reduce the use of advanced treatment technologies in this patient population.”
Disclosure: The researchers report honoraria from the American Urologic Association, consultant roles with ArborMetrix and United Healthcare, and stock ownership in HistoSonics.
Perspective
Back to TopNathan Sheets, MD, MSE
Jacobs and colleagues provide an interesting study looking at the adoption of prostate cancer treatment technologies, such as IMRT and robotic prostatectomy, among men at low risk for dying from prostate cancer. Their primary finding that these newer technologies have been rapidly adopted has been well described, and it underscores a common pattern of medical technology adoption preceding evidence of clinical superiority. Whether this adoption is clinically or financially driven is a source of substantial debate.
Interestingly, the study dovetails with a recent Government Accountability Office report suggesting that, although IMRT in some practices has decreased in use, referring physicians with a stake in radiation payments are much more likely to recommend IMRT than options such as active surveillance for prostate cancer. It therefore seems likely that the increased use of IMRT in this low-risk population is being driven in part by this physician self-referral.
Perspective
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E. David Crawford, MD
When most men are confronted with the word “cancer," they choose to have a treatment. This is the basis of the article by Jacobs and colleagues, who explored how advanced technologies are being employed in these men. There has been a lot of marketing hype regarding several treatments for localized disease, including robotic prostatectomy and certain forms of radiation therapy. The challenge we face is separating diagnosis from treatment, and distinguishing indolent from aggressive cancers. To that end, we rely on three features: PSA, Gleason score and clinical stage. These can be misleading, in part due to the random nature of transrectal biopsies. They may miss a high-grade cancer, which leads to inappropriate management.
Fortunately, in the past 2 years, several new molecular markers have become available. The first is ConfirmMDx (MDxHealth), an epigenetic test that — when positive — raises the suspicion for the presence of cancer. Failure to detect epigenetic methylation changes is a powerful indicator of a benign gland, as the test has a 90% negative predictive value. There are two other marker tests — Prolaris (Myriad Genetics) and oncotypeDX (Genomic Health Inc.) — that can be used to help make more reliable recommendations for active surveillance. Both of those look at cell cycle progression and other genes.
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