Utilization of minimally invasive radical prostatectomy, intensity-modulated radiation therapy on the rise

Boston-Despite limited comparative effectiveness data, the utilization of higher-cost therapies for localized prostate cancer such as minimally invasive radical prostatectomy (MIRP) and intensity-modulated radiation therapy (IMRT) is increasing dramatically in men 65 years of age and older, say researchers from Brigham and Women's Hospital, Boston.

"As a society, we are very eager to adopt new technologies, and we tend to adopt these technologies before there are clear data delineating comparative benefits," said first author Wesley Choi, MD, a former urologic oncology fellow at Brigham and Women's working with Paul L. Nguyen, MD, Jim C. Hu, MD, MPH, and colleagues. "This characteristic lies against a backdrop of increasing costs that are becoming a substantial concern in the U.S."

Utilization of IMRT showed an even more dramatic increase. In men diagnosed with prostate cancer in 2002 and treated with radiation therapy, the technology was employed 28.7% of the time. In men diagnosed in 2005 and treated with radiation, IMRT was employed 81.7% of the time (p<.001).

The utilization of these therapies evidenced demographic characteristics that the study detected but was not designed to explain.

"We found that African-Americans were less likely to undergo IMRT and MIRP and that Asian men were more likely to undergo these higher-cost treatments. In addition, men living in census tracts with greater than 90% high school education were more likely to undergo the higher-cost treatments," Dr. Choi said.

He presented the findings at the 2010 AUA annual meeting in San Francisco, and the study data were recently published online in the Journal of Clinical Oncology (March 14, 2011).

The demographic differences were in instances both significant and substantial. For instance, 40.1% of the men undergoing IMRT lived in census tracts with a higher educational attainment (>90% high school graduates) compared to only 29% of men undergoing 3-D CRT.

Income, education factors?

Income was also a factor in selecting radiation therapies. Men with annual incomes ≥$60,000 were more likely to undergo IMRT vs. 3-D CRT (20.9% vs. 12.3%).

These same demographic characteristics were found in the data on invasive surgical procedures. Half (50.1%) of the men undergoing MIRP lived in more highly educated census tracts (>90% high school graduates) compared to 40% of men undergoing ORP. More than one-third (35.4%) of men who underwent MIRP had ≥$60,000 annual income compared to 21.1% of men who underwent ORP.

"Some clinical factors also appeared to matter. Men with clinical stage T1 disease, as well as those with higher-grade tumors, were more likely to undergo IMRT and MIRP, as were those with low or no comorbidity," said Dr. Choi, currently a staff urologist with Kaiser Permanente in Anaheim, CA.

"We are now studying the actual increase in Medicare expenditures that result from the adoption of these therapies. Today's realities dictate that we must weigh the benefits of these therapies with their costs as new modalities are introduced," Dr. Choi concluded.