Urologists who incorporate intensity-modulated radiation therapy services into their own practices are much more likely to refer men with newly diagnosed nonmetastatic prostate cancer for IMRT than are other urologists, according to a report. The study was published online Oct. 23 in the New England Journal of Medicine.
Referral to an IMRT service in which the urologist holds a financial stake, also known as self-referral, is controversial because it poses a conflict of interest for the referring physician/investor or physician/owner. Yet many urologists have incorporated IMRT, which enjoys a high reimbursement rate, into their practices: An estimated 19% of urology practices in the United States included IMRT as of 2012, said Jean M. Mitchell, Ph.D., of Georgetown University, Washington.
The increase in IMRT has occurred "despite evidence that all treatments yield similar outcomes" for this type of cancer. "The findings raise concerns regarding the appropriate use of IMRT, especially among older Medicare beneficiaries, for whom the risks of undergoing intensive irradiation probably exceed the benefits," she said.
Dr. Mitchell compared the frequency of IMRT use in two analyses. In the first, she examined claims data for Medicare fee-for-service beneficiaries residing in 26 geographically dispersed states who were newly diagnosed as having nonmetastatic prostate cancer during a 5-year period, when many practices began offering their own IMRT services.
She then identified 35 self-referring urology practices in those states and matched them with an equal number of non–self-referring urology practices in the same area, which served as controls.
Dr. Mitchell found that among beneficiaries treated by self-referring urologists, the rate of IMRT referral increased by over 19%, from 13.1% to 32.3%, during the study period. In contrast, the rate of IMRT referral did not change in patients treated by non–self-referring urologists.
At the same time, the rates of use of two other treatments for noninvasive prostate cancer – brachytherapy and hormone use – fell by a combined 21% in the self-referring practices, she said (N. Engl. J. Med. 2013 Oct. 23 [doi:10.1056/NEJMsa1201141]).
In the second analysis, Dr. Mitchell assessed the records for urologists working at 11 self-referring private practices and urologists employed at 11 non–self-referring cancer centers participating in the National Comprehensive Cancer Network (NCCN) during the same time period. IMRT use by self-referring urologists increased from 9% to 42%, during the course of the study. Another 4.5% of men treated by self-referring urologists also obtained IMRT but attended a different provider to do so.
As in the other study, the corresponding rates of brachytherapy and hormone use in the self-referring practices dropped; in this case by 25%. Active surveillance decreased by 6% and the use of prostatectomy and other procedures declined by 4%.
"By contrast, there was virtually no change in the practice patterns of urologists employed by NCCN centers," where the rate of IMRT use held steady throughout the study period at approximately 8%.
"These findings are consistent with the results of other studies showing substantial increases in the frequency of use of advanced imaging techniques, clinical laboratory testing, and anatomical-pathology services by self-referring physicians," she said.
Financial incentives that may have contributed to the increased use of IMRT are clear. Marketing materials from one company that sells the technology to urologists claim that "treating 1.5 new patients monthly with IMRT could generate more than $425,000 in additional revenue per urologist annually," Dr. Mitchell said.
In some cases, the pressure to simply recoup the costs of investing in IMRT rather than to generate "extra" income may have contributed. Establishing IMRT in a urology practice, which includes hiring advanced support staff, can cost $2 million.
In other cases, "urologists may integrate IMRT into their practice because they believe this treatment will reduce the risk of adverse events and improve quality of life." However, the evidence shows that IMRT is no better than alternative treatments, and that each treatment offers pros and cons that affect quality of life, she added.
This study was funded by the American Society for Radiation Oncology and Georgetown University. Dr. Mitchell reported no financial conflicts of interest.