“Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced treatment technologies,” the researchers wrote in their report. They also noted that the increased use of intensity-modulated radiotherapy, or IMRT, and robotic prostatectomy could largely be explained because they were seen as replacements for other therapies such as external beam radiation treatment, or EBRT, and open radical prostatectomy.
The researchers wrote that IMRT and robotic surgery were “generally perceived as being more targeted and less toxic” than earlier prostate cancer treatments, but startup costs for both can be near $2 million. They note that men with low-risk cancer can live for 20 years after diagnosis and die from other causes. But they also note that “patients who choose observation may live with a high level of anxiety knowing that they have cancer,” and that robotic prostatectomy use was more common among younger patients.
“A perceived improvement in outcomes compared with prior alternatives may make these advanced treatment technologies seem more palatable,” the researchers wrote. “Financial incentives—through ownership opportunities, growing market share, and fee-for-service reimbursement—may be too strong to overcome.”
Dr. Ralph Weichselbaum, chairman of radiation and cellular oncology for University of Chicago Medicine, agreed with the study's findings and said the authors may be understating the issue.
“If you pay doctors to do stuff, we do it,” Weichselbaum said. “I think they're pretty gentle here. Doctors are doing a lot of expensive, unnecessary stuff—that seems to be the take-home message.”
Some experts have pushed for calling low-risk tumors something other than “cancer,” and Weichselbaum said this could help ease some fears and reduce a patient's need “to do something.”
“I think it's very hard for Americans to accept we have cancer that can be observed—because we attach that moniker to it, we're scared,” he said.
The National Cancer Institute and several partners are carrying out a randomized controlled trial comparing the effectiveness of radiation, surgery and surveillance. The results of the trial—dubbed Surveillance Therapy Against Radical Treatment, or START—won't be available for five to 10 years, according to the JAMA story.
The researchers used a Medicare database to identify 23,633 men treated with IMRT, 3,926 treated with EBRT, 5,881 who underwent robotic prostatectomy, 6,123 who had an open radical prostatectomy, and 16,384 observation patients who didn't undergo a procedure. They acknowledged that including data only on men older than 66 was a limitation of their study. They note, however, that nearly two-thirds of cancer patients are age 65 years or older.
Follow Andis Robeznieks on Twitter: @MHARobeznieks