New, Pricey Prostate Cancer Treatments May Be Overused: Study

The use of advanced prostate cancer treatments has increased among men who arguably will derive little benefit from the expensive new technologies, a new study suggests.

The use of intensity-modulated radiotherapy (IMRT) and robotic prostatectomy to treat prostate cancer patients at low risk of dying from the disease increased from 32 percent in 2004 to 44 percent in 2009, researchers found in reviewing Medicare patient data. These technologies also were utilized more often to treat men with prostate cancer who were at high risk of dying for some reason other than their cancer, increasing from 36 percent in 2004 to 57 percent in 2009. Use of advanced technology to treat those with both low-risk disease and a high risk of non-cancer mortality went from 25 percent in 2004 to 34 percent in 2009.

"The implementation of these technologies occurred in populations at a time when there was an increase in awareness that some prostate cancers might not warrant treatment," said study co-author Dr. Brent Hollenbeck, an associate professor of urology and director of the Herbert H. and Grace A. Dow Division of Health Services Research at the University of Michigan. The findings were published in the June 26 issue of the Journal of the American Medical Association. Doctors who treat prostate cancer are rethinking the options they should pursue with patients, said Dr. Durado Brooks, director of prostate and colorectal cancers for the American Cancer Society. Most prostate cancers are slow-growing, and the surgeries and therapies used to treat them can drastically affect a man's quality of life, causing incontinence and impotence.

"Many of these men have a variety of other health issues that are likely to shorten their lives," Brooks said. What's more, new technologies like IMRT, robotic prostatectomy and proton beam therapy have not been shown to be any more effective in treating prostate cancer or avoiding side effects than established procedures like traditional external beam radiation treatment (EBRT) and open radical prostatectomy. "The hope with these advanced treatments is that we would decrease these side effects, but it hasn't been borne out in clinical trials," Brooks said. This has led to a movement toward observational approaches like watchful waiting, where the doctor only steps in when symptoms appear or worsen, or active surveillance, in which testing continues but no therapeutic action occurs. "In both situations, no active treatment is applied until evidence shows the prostate cancer is progressing," Brooks said. The research team, led by doctors at the University of Michigan, reviewed thousands of Medicare patient records, focusing on men who underwent treatment using IMRT, EBRT, robotic prostatectomy, open radical prostatectomy or observation. IMRT uses multiple small radiation beams to precisely target a tumor, changing the intensity and shape of the beams to reduce exposure of healthy tissue and limit side effects. Robotic prostatectomy uses robot technology to create precise incisions that are more likely to spare the nerves surrounding the prostate. The researchers found that the older, time-tested procedures are being shunted aside in favor of the more advanced technologies, which could have a huge impact on health care spending in the United States.

"Both treatments are considerably more expensive than the prior standards," the authors wrote. "Start-up costs for both approach $2 million. Further, IMRT is associated with higher total episode payments, which translate into an additional $1.4 billion in spending annually. Thus, the implications of any potential overtreatment with these advanced treatment technologies are amplified in financial terms." Brooks said patient demand could be one explanation for the increasing use of advanced technology. "Less than 10 percent of U.S. men who are diagnosed with prostate cancer opt for an observational approach, and the fact is about 30 percent to 40 percent have slow-growing prostate cancer or other health issues that would make them candidates for observation," he said.

That demand, however, is being driven in part by hospitals and treatment centers touting the potential benefits of new technologies. For example, a 2011 study found that nine out of every 10 hospitals with robotic prostate surgery facilities claimed on their websites that robotic prostatectomy is better than conventional surgery -- less pain, shorter recovery, less scarring and less blood loss. "Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced treatment technologies," the study authors wrote. "The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain."