The use of advanced treatment technologies, such as intensity-modulated radiotherapy and robotic prostatectomy, has increased among men unlikely to die from prostate cancer, according to a retrospective analysis of data from almost 56,000 men diagnosed with prostate cancer between 2004 and 2009. Among these patients, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13%, or 129.2 per 1,000 patients diagnosed with prostate cancer, to 24%, or 244.2 per 1,000 patients diagnosed with prostate cancer (P < .001).
“Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced treatment technologies,” the researchers noted in their report published in JAMA.
The study compared the use of advanced treatment technologies to the prior standards of traditional external-beam radiation therapy, open radical prostatectomy, and observation among men with low-risk prostate cancer, those with a high risk of noncancer mortality, and those with both low-risk disease and a high risk of noncancer mortality.
“The use of advanced treatment technologies for prostate cancer was common among patients with low-risk disease and among those with a high risk of noncancer mortality,” the researchers reported. “The most common treatment modality was [intensity-modulated radiotherapy], which accounted for the greatest use among men who stand the least to gain in terms of survival. The increasing use of both [intensity-modulated radiotherapy] 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 radiotherapy] and open radical prostatectomy.”
Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the researchers identified 23,633 men who underwent intensity-modulated radiotherapy, 6,123 who had open radical prostatectomy, 5,881 who had robotic prostatectomy, and 3,926 who had external-beam radiotherapy, along with 16,384 men who had observation alone. In this cohort, 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 use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% to 34% (P < .001).
“The absolute magnitude of the use of advanced treatment technologies in these populations has two important implications,” the authors noted. “First, both treatments are considerably more expensive than the prior standards. Thus, the implications of any potential overtreatment with these advanced treatment technologies are amplified in financial terms. Second, and perhaps more important, 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,” they continued.
“Our findings suggest that, even during this period of enhanced stewardship, incentives favoring the diffusion of these technologies outweighed those related to implementing a more conservative management strategy,” the authors commented. ■
Jacobs BL, et al: JAMA 309:2587-2595, 2013.