Adoption of New, Costlier Therapies For Prostate Cancer Precedes Evidence

SAN FRANCISCO — The use of new, more expensive therapies for prostate cancer increased rapidly during a recent 4-year period, despite a lack of consensus on their effectiveness relative to that of older, less expensive therapies, researchers reported at a symposium on genitourinary cancers.

In a cross-sectional sample of 58,581 older U.S. men with nonmetastatic prostate cancer, the use of minimally invasive radical prostatectomy rose 19-fold, of intensity-modulated radiation therapy (IMRT) almost 3-fold, and of the combination of brachytherapy plus IMRT roughly 4-fold. The use of older therapies fell correspondingly.

“Despite limited comparative effectiveness data, there was a rapid increase in utilization of these more expensive therapies for prostate cancer,” said lead investigator Dr. Paul L. Nguyen. “Potential benefits really must be weighed against the added costs as newer, expensive therapies are introduced.”

The researchers used the linked SEER (Surveillance, Epidemiology, and End Results)–Medicare database to identify men aged 65 years or older who received a diagnosis of nonmetastatic prostate cancer between 2002 and 2005 and who were not enrolled in an HMO. Treatments were ascertained by using procedural codes.

The pattern of relative use of treatment modalities remained constant between 2002 and 2005, with external-beam radiation therapy used most commonly, followed by brachytherapy, and then by surgery. But there were major shifts within each modality in the specific therapies used, Dr. Nguyen reported at the symposium, which was sponsored by the American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Urologic Oncology.

Among men who had surgery, the proportion who had minimally invasive (laparoscopic or robotic) radical prostatectomy increased 19-fold, from 1.5% in 2002 to 28.7% in 2005. Meanwhile, the proportion having open prostatectomy fell.

Among men who had external-beam radiation therapy, the proportion who had IMRT almost tripled, from 28.7% to 81.7%. At the same time, the use of 3D-conformal radiation therapy decreased.

Finally, among men who had brachytherapy, the proportion also treated with IMRT roughly quadrupled, from 8.5% to 31.1%. Meanwhile, the proportion receiving brachytherapy plus 3D-conformal radiation therapy fell, and the proportion receiving brachytherapy alone was unchanged, said<Dr. Nguyen, director of prostate brachytherapy at the Dana-Farber Cancer Institute and Brigham and Women's Hospital, both in Boston.

Compared with men who had open prostatectomy, men who had minimally invasive radical prostatectomy were more likely to be highly educated, reside in a high-income neighborhood, and live in the Northeast or the West; were more likely to have a high tumor grade, a clinical T1 stage, and limited comorbidity; and were more likely to be Asian and less likely to be black or Hispanic.

All of these factors were also associated with receiving IMRT as opposed to 3D-conformal radiation therapy, except for race/ethnicity. IMRT recipients were more likely to be Asian and more likely to be white (but less likely to be black (P

“Comparative effectiveness research into these more expensive therapies has been pretty limited. Certainly, there are no randomized trials that tell us that the more expensive therapy is better than the less expensive therapy,” Dr. Nguyen commented.

An analysis suggesting that IMRT is cost effective (Int. J. Radiat. Oncol. Biol. Phys. 2006;66:408-15) was published after the use of this therapy was already widespread. “So we have to ask ourselves, did we do this backwards, because … it was after the fact that we found it was cost effective,” he said. “What if we had found out it wasn't?”

The findings have important implications for guiding the use of future technologies, such as proton therapy, Dr. Nguyen observed. “Even if there is a clinical benefit to these more expensive therapies, it's still fair to ask [whether] these benefits [will] outweigh the added costs,” he said.

Disclosures: Dr. Nguyen reported having no conflicts of interest related to the study.

SAN FRANCISCO — The use of new, more expensive therapies for prostate cancer increased rapidly during a recent 4-year period, despite a lack of consensus on their effectiveness relative to that of older, less expensive therapies, researchers reported at a symposium on genitourinary cancers.

In a cross-sectional sample of 58,581 older U.S. men with nonmetastatic prostate cancer, the use of minimally invasive radical prostatectomy rose 19-fold, of intensity-modulated radiation therapy (IMRT) almost 3-fold, and of the combination of brachytherapy plus IMRT roughly 4-fold. The use of older therapies fell correspondingly.

“Despite limited comparative effectiveness data, there was a rapid increase in utilization of these more expensive therapies for prostate cancer,” said lead investigator Dr. Paul L. Nguyen. “Potential benefits really must be weighed against the added costs as newer, expensive therapies are introduced.”

The researchers used the linked SEER (Surveillance, Epidemiology, and End Results)–Medicare database to identify men aged 65 years or older who received a diagnosis of nonmetastatic prostate cancer between 2002 and 2005 and who were not enrolled in an HMO. Treatments were ascertained by using procedural codes.

The pattern of relative use of treatment modalities remained constant between 2002 and 2005, with external-beam radiation therapy used most commonly, followed by brachytherapy, and then by surgery. But there were major shifts within each modality in the specific therapies used, Dr. Nguyen reported at the symposium, which was sponsored by the American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Urologic Oncology.

Among men who had surgery, the proportion who had minimally invasive (laparoscopic or robotic) radical prostatectomy increased 19-fold, from 1.5% in 2002 to 28.7% in 2005. Meanwhile, the proportion having open prostatectomy fell.

Among men who had external-beam radiation therapy, the proportion who had IMRT almost tripled, from 28.7% to 81.7%. At the same time, the use of 3D-conformal radiation therapy decreased.

Finally, among men who had brachytherapy, the proportion also treated with IMRT roughly quadrupled, from 8.5% to 31.1%. Meanwhile, the proportion receiving brachytherapy plus 3D-conformal radiation therapy fell, and the proportion receiving brachytherapy alone was unchanged, said<Dr. Nguyen, director of prostate brachytherapy at the Dana-Farber Cancer Institute and Brigham and Women's Hospital, both in Boston.

Compared with men who had open prostatectomy, men who had minimally invasive radical prostatectomy were more likely to be highly educated, reside in a high-income neighborhood, and live in the Northeast or the West; were more likely to have a high tumor grade, a clinical T1 stage, and limited comorbidity; and were more likely to be Asian and less likely to be black or Hispanic.

All of these factors were also associated with receiving IMRT as opposed to 3D-conformal radiation therapy, except for race/ethnicity. IMRT recipients were more likely to be Asian and more likely to be white (but less likely to be black (P

“Comparative effectiveness research into these more expensive therapies has been pretty limited. Certainly, there are no randomized trials that tell us that the more expensive therapy is better than the less expensive therapy,” Dr. Nguyen commented.

An analysis suggesting that IMRT is cost effective (Int. J. Radiat. Oncol. Biol. Phys. 2006;66:408-15) was published after the use of this therapy was already widespread. “So we have to ask ourselves, did we do this backwards, because … it was after the fact that we found it was cost effective,” he said. “What if we had found out it wasn't?”

The findings have important implications for guiding the use of future technologies, such as proton therapy, Dr. Nguyen observed. “Even if there is a clinical benefit to these more expensive therapies, it's still fair to ask [whether] these benefits [will] outweigh the added costs,” he said.

Disclosures: Dr. Nguyen reported having no conflicts of interest related to the study.

SAN FRANCISCO — The use of new, more expensive therapies for prostate cancer increased rapidly during a recent 4-year period, despite a lack of consensus on their effectiveness relative to that of older, less expensive therapies, researchers reported at a symposium on genitourinary cancers.

In a cross-sectional sample of 58,581 older U.S. men with nonmetastatic prostate cancer, the use of minimally invasive radical prostatectomy rose 19-fold, of intensity-modulated radiation therapy (IMRT) almost 3-fold, and of the combination of brachytherapy plus IMRT roughly 4-fold. The use of older therapies fell correspondingly.

“Despite limited comparative effectiveness data, there was a rapid increase in utilization of these more expensive therapies for prostate cancer,” said lead investigator Dr. Paul L. Nguyen. “Potential benefits really must be weighed against the added costs as newer, expensive therapies are introduced.”

The researchers used the linked SEER (Surveillance, Epidemiology, and End Results)–Medicare database to identify men aged 65 years or older who received a diagnosis of nonmetastatic prostate cancer between 2002 and 2005 and who were not enrolled in an HMO. Treatments were ascertained by using procedural codes.

The pattern of relative use of treatment modalities remained constant between 2002 and 2005, with external-beam radiation therapy used most commonly, followed by brachytherapy, and then by surgery. But there were major shifts within each modality in the specific therapies used, Dr. Nguyen reported at the symposium, which was sponsored by the American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Urologic Oncology.

Among men who had surgery, the proportion who had minimally invasive (laparoscopic or robotic) radical prostatectomy increased 19-fold, from 1.5% in 2002 to 28.7% in 2005. Meanwhile, the proportion having open prostatectomy fell.

Among men who had external-beam radiation therapy, the proportion who had IMRT almost tripled, from 28.7% to 81.7%. At the same time, the use of 3D-conformal radiation therapy decreased.

Finally, among men who had brachytherapy, the proportion also treated with IMRT roughly quadrupled, from 8.5% to 31.1%. Meanwhile, the proportion receiving brachytherapy plus 3D-conformal radiation therapy fell, and the proportion receiving brachytherapy alone was unchanged, said<Dr. Nguyen, director of prostate brachytherapy at the Dana-Farber Cancer Institute and Brigham and Women's Hospital, both in Boston.

Compared with men who had open prostatectomy, men who had minimally invasive radical prostatectomy were more likely to be highly educated, reside in a high-income neighborhood, and live in the Northeast or the West; were more likely to have a high tumor grade, a clinical T1 stage, and limited comorbidity; and were more likely to be Asian and less likely to be black or Hispanic.

All of these factors were also associated with receiving IMRT as opposed to 3D-conformal radiation therapy, except for race/ethnicity. IMRT recipients were more likely to be Asian and more likely to be white (but less likely to be black (P

“Comparative effectiveness research into these more expensive therapies has been pretty limited. Certainly, there are no randomized trials that tell us that the more expensive therapy is better than the less expensive therapy,” Dr. Nguyen commented.

An analysis suggesting that IMRT is cost effective (Int. J. Radiat. Oncol. Biol. Phys. 2006;66:408-15) was published after the use of this therapy was already widespread. “So we have to ask ourselves, did we do this backwards, because … it was after the fact that we found it was cost effective,” he said. “What if we had found out it wasn't?”

The findings have important implications for guiding the use of future technologies, such as proton therapy, Dr. Nguyen observed. “Even if there is a clinical benefit to these more expensive therapies, it's still fair to ask [whether] these benefits [will] outweigh the added costs,” he said.

Disclosures: Dr. Nguyen reported having no conflicts of interest related to the study.