By Michelle Fay Cortez
MINNEAPOLIS — Urologists who buy their own equipment to provide expensive radiation treatment are more likely to use it to treat prostate cancer even when the benefit for patients is unclear, research shows.
Prostate cancer is the most common tumor diagnosed in the U.S., where an estimated 238,590 men were told they had the disease this year. While only about 12 percent, or 29,270 men, will die from it this year, all will have to decide how, and whether, they want to treat the cancer.
A study published in the New England Journal of Medicine Thursday suggests that profits urologists make from referring patients to their own radiation facilities play an outsized role in the treatment decisions. One third of men whose doctors own radiation equipment get the therapy at a cost of about $35,000 per treatment course. The same doctors prescribed the therapy for just 13 percent of their patients before they had their own equipment and could profit directly.
"The results are striking," said Jean Mitchell, the author of the report and a professor of public policy at Georgetown University in Washington, D.C. "It does appear that what's driving this is financial incentives linked to ownership. Their behavior changes dramatically."
Prostate cancer treatments include radiation, hormone therapy and surgery. The men treated with radiation in the study had low risk disease: newly diagnosed prostate cancer that hadn't spread in the body. The 10-year survival rate for all prostate cancer is 98 percent. Simple monitoring is also an appropriate approach for men with non-metastatic disease.
Mitchell didn't have access to patient-level data, so she couldn't analyze the characteristics of each man to determine if treatment was appropriate.
Instead, she compared the use of the technology, called intensity-modulated radiation therapy, among urologists before and after they integrated the $2 million machines into their practices. She also analyzed its use among doctors who didn't own the technology and urologists at 11 National Comprehensive Cancer Network centers, the country's gold standard of care.
Using claims data from the U.S. government's Medicare insurance program for the elderly, Mitchell found that urologists who didn't own the equipment prescribed IMRT for 15.6 percent of their patients in 2010, compared with 14.3 percent five years earlier. Its use among the NCCN doctors stayed constant at about 8 percent, while it soared to 44 percent among a matched-group of doctors who started to refer patients to their own radiation treatment facilities.
"It's crazy the way the system is set up," Mitchell said in a telephone interview. "The patients are going to do what their physician tells them to do. The patient becomes almost like an ATM machine, with the doctor extracting as much revenue as they can."
The leader of a national urologists' group said the doctors who own radiation oncology equipment use the technology appropriately.
Mitchell's study "shows that less than one-third of newly diagnosed prostate cancer patients who sought treatment from an integrated urology group received IMRT," Deepak Kapoor, president of the Large Urology Group Practice Association, said in a statement. "This figure is fully in line with data from academic literature that predates the development of integrated groups."
Physicians in general aren't allowed to refer their patients for treatment in facilities that they also own, because of the financial conflict of interest. However, radiation, as well as in-office ancillary services, such as doing blood work and x-rays, are exempted under U.S. law. The exception was created for patient convenience. It's unclear why radiation, which is a treatment and not an ancillary service, was exempted, Mitchell said.
The situation may actually harm some patients. The analysis found that doctors who owned the IMRT therapy were treating men ages 80 and older just as aggressively as younger men with early stage prostate cancer. Since the cancer is generally slow- growing, and radiation can carry immediate side effects, including erection problems and urinary symptoms, the older patients may experience only the harms and no benefits.
"The findings raise concerns regarding the appropriate use of IMRT, especially among older Medicare beneficiaries," Mitchell wrote. "Permitting urologists to self-refer for IMRT may contribute to increased use of this expensive therapy."
The study bolsters similar findings with other forms of self-referral. In fact, some urologists have incorporated pathology labs into their practices, boosting the number of biopsies they perform, Mitchell said. Research has found similar results in other areas, including advanced imaging and surgery at physician-owned specialty hospitals.