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Despite new guidelines recommending “watchful waiting” for men diagnosed with prostate cancers that carry a low risk of death, more are undergoing potentially unnecessary, but expensive, treatment with high-tech machines according to a large study published Tuesday in the Journal of the American Medical Association (JAMA).
What to do about prostate cancer -- including whom to screen for it and when to treat, or not to treat, has long provoked controversy. The U.S. Preventive Services Task Force advises against routine screening for most men, and recommends active surveillance, not treatment, for men diagnosed with low-risk disease.
The study -- which concludes that “use of advance treatment technologies has increased” among low-risk patients -- found that between 2004 and 2009, use of robotic surgery and intensity-modulated radiotherapy (IMRT) both saw significant increases in men most experts regard as inappropriate candidates for such treatments.
Among 55,947 male Medicare recipients age 66 and over, use of the high-tech therapies jumped from 36 percent to 57 percent in men who are, statistically speaking, much more likely to die of something else, like cardiovascular disease or another form of cancer, than from prostate disease. Rates of use also increased in men with low overall risk of death and low-risk prostate cancer, and in men with both low-risk cancer and a high risk of death from other causes.
Because prostate cancers are often slow growing, experts suggest not treating low-risk disease because using surgery, radiation,, and drugs that lower androgen hormones -- all common therapies -- cause serious side effects like incontinence and impotence.
"There continues to be pervasive over-treatment of men with low-risk prostate cancer who are very unlikely to benefit from such treatment, and who would be better served in many cases -- likely in most cases -- with active surveillance," Matthew Cooperberg, assistant professor of urology at the Helen Diller Family Comprehensive Cancer Center, University of California San Francisco told NBC News.
There are a number of reasons for the rise in sophisticated treatment, but the most obvious is money, researcher Brent Hollenbeck, associate professor of urology and director of the Dow Division for Urologic Health Services Research at the University of Michigan, told NBC News.
Both IMRT and robotic surgery systems cost about $2 million to establish, Hollenbeck said. Hospitals and clinics want to recoup that investment.
“There are inherent incentives in the fee-for-service delivery system to over treat for low risk prostate cancer,” Hollenbeck, the study's author, said.
Cooperberg agrees that financial incentives could be a major factor in rising rates of men with prostate cancer receiving high-tech treatments.
"This is particularly true for IMRT, which is reimbursed very richly compared to other treatment modalities," Cooperberg said. "Other factors, malpractice fears in not treating cancer and cultural imperatives -- not just for high technology but also for 'active' treatment in general rather than "passive" surveillance -- also play significant roles."
As a 2010 Medicare investigation revealed, and the Wall Street Journal reported, IMRT costs Medicare roughly $40,000 per patient and is often used by “self-referring” physicians who send patients to treatment centers in which the doctors themselves own an interest.
Another study by Hollenbeck and his Michigan colleague Bruce Jacobs released in 2012 in Health Affairs documented a 1,000 percent increase in the use of the high-tech radiotherapy between 2001 and 2007. The cost of that treatment is between $15,000 and $20,000 more than standard therapies, the authors stated.
The health care system cost of replacing standard radiation with IMRT could be $1.4 billion per year, the Michigan group has estimated.
But the issue is more complex than simple economics. The new gadgetry, especially IMRT, which promises to enable doctors to use higher doses of radiation and more precisely target the cancer, seems less invasive and risky to many patients, Hollenbeck suggested. So even though a man may be at low risk of dying from his cancer, treatment may be appealing as an easy way to ease the anxiety of living with the “cancer” label.
“New, fancy machines cost more and that is what [patients] want,” Hollenbeck said. “That is American culture: new is better. But most newer technologies are rolled out with limited evidence [they provide better outcomes]. That evidence is gathered while the technology is in the process of diffusing.”
In fact, research comparing results of IMRT to other forms of treatment are mixed. Some studies have suggested men using IMRT suffer reduced side-effects. But new research tracking longer term results showed no significant difference in “gastrointestinal morbidity…urinary incontinent morbidity, or erectile dysfunction” and no significant difference in “subsequent treatment for recurrent disease.”