Urologists' Use of IMRT for Prostate Cancer

Posted by • October 25th, 2013

Some urology groups have integrated intensity-modulated radiation therapy (IMRT) into their practice, which allows them to refer patients to their own practice for IMRT. This analysis showed a substantial increase in IMRT use by urologists who acquired ownership of IMRT services.

As permitted by the exception for in-office ancillary services in the federal prohibition against self-referral, some urology groups have integrated IMRT, a radiation treatment with a high reimbursement rate, into their practices.

Clinical Pearls

• What percentage of men in the United States with a new diagnosis of prostate cancer had clinically localized disease in 2011, and what is the overall 10-year survival among men with prostate cancer?

In 2011, nearly 240,900 men in the United States received a new diagnosis of prostate cancer. Approximately 90% of these men had clinically localized disease, which was indolent in most cases. The 10-year survival rate among all men with prostate cancer is 98%.

• What is IMRT, and how does it differ from brachytherapy?

IMRT is an advanced form of three-dimensional radiation therapy, which involves the use of a computer-driven machine that revolves around the patient as it delivers radiation. Radiation beams are aimed at the prostate from multiple angles. Intensity can be adjusted to maximize the dose targeted at the cancerous tissue and minimize the dose to surrounding healthy tissue. Brachytherapy with the use of low-dose-rate isotypes involves permanent implantation of seeds that emit a low dose of radiation over a period of several months. Some patients also receive a boost of external-beam radiation therapy or androgen-deprivation therapy. The authors indicate that despite substantial variation in reimbursement, evidence suggests that for low-risk disease, the alternative treatments are clinically equivalent in terms of survival, and that no single treatment approach is preferable with respect to the risk of adverse events and implications for quality of life.

Morning Report Questions

Q: What were the primary results of this study, which evaluated the use of IMRT by urologists who referred to their own practices (self-referred) for this therapy as compared to non-self-referring urologists?

A: The results of this study indicate that urologist self-referral is associated with large increases in the rate of IMRT use for Medicare beneficiaries with newly diagnosed, nonmetastatic prostate cancer.

Among beneficiaries treated by self-referring urologists in private practice, the rate of IMRT referral increased from 13.1 to 32.3%, an increase of 19.2 percentage points (P<0.001).

Table 2. Treatment Provided for Men with Newly Diagnosed, Nonmetastatic Prostate Cancer in the 35 Matched Groups of Self-Referring and Non-Self-Referring Urologists in Private Practice, According to Self-Referral Status and Ownership Period.

Q: During the study period, what changes were seen in other forms of treatment for prostate cancer among self-referring urologists, and how do the results compare with non-self-referring urologists?

A: Rates of brachytherapy and hormone use fell by 13 and 8 percentage points, respectively (P<0.001). Changes in use rates for prostatectomy and active surveillance were inconsequential. By contrast, the rate of IMRT referral among patients treated by non-self-referring urologists was virtually unchanged between the preownership and ownership periods, from 14.3 to 15.6%, which was an increase of 1.3 percentage points (P=0.05). Use rates for the remaining treatment options by non-self-referring urologists remained stable.

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