Radiation therapy in the spotlight (Part 2 of 2)

Do economics and potential profits drive treatment recommendations?

According to the American Cancer Society, nearly 187,000 men will learn this year that they have prostate cancer. For many of them, deciding how to treat the disease — or even whether to treat it — isn’t easy. They can’t simply plug variables, such as likelihood of a cure and future quality of life, into a complex mathematical equation and solve for x, their ideal treatment. Even after they read their pathology report, seek second opinions, and research treatment options online, many remain confused. Inevitably, that prompts the question: “What would you do, Doctor?”

Unfortunately, with a shortage of definitive data proving one therapy superior to another, financial motives might influence the physician’s response. With reimbursements from insurers falling, physicians under economic pressure may subtly steer patients toward the treatment with the highest reimbursement rate. Similarly, institutions that launch new facilities with state-of-the-art technology may over-promote the technology to recoup their investment, even if that particular technology has not been thoroughly evaluated.

Although they felt that the vast majority of physicians make treatment recommendations based on a patient’s particular medical situation, participants in a recent roundtable discussion on radiation therapy agreed that profit motives affect practice. They referred to an article in The New York Times about the potential profit associated with intensity-modulated radiation therapy (IMRT).* Dozens of urologists, according to the article, have purchased IMRT equipment for about $3 million and, banking on reimbursements of nearly $50,000 per patient, increasingly recommend the treatment over other proven approaches. In comparison, physicians estimate that their institutions are paid about $14,000 for brachytherapy.

Adamant about the need for treatments that limit side effects like impotence and incontinence, patients have been pressing hard for access to newer technologies, such as proton beam therapy. While proton beam therapy can effectively control prostate cancer, it costs more — in the neighborhood of $60,000. Yet the superiority of proton beam therapy over IMRT, for example, has not been proven, and a recent study concluded that proton beam therapy is not a cost-effective treatment for most prostate cancer patients. (For details on this study and related articles, see “Economics of radiation therapy, ” below.)

Here, in part 2 of the roundtable discussion, these three Harvard experts discuss the financial issues related to radiation therapy:

• Irving Kaplan, M.D., an assistant professor of radiation oncology at Harvard Medical School and a radiation oncologist at Beth Israel Deaconess Medical Center in Boston. He has published extensively on various topics related to prostate cancer.
• Carolyn Lamb, M.D., an instructor in radiology at Harvard Medical School and a radiation oncologist at Mount Auburn Hospital in Cambridge, Mass. She is a member of the American Society for Therapeutic Radiology and Oncology and has published a number of scientific papers on prostate cancer treatment, including the implantation of radioactive seeds. She also serves on Perspectives’ editorial board.
• Anthony L. Zietman, M.D., a professor of radiation oncology at Harvard Medical School and a radiation oncologist at Massachusetts General Hospital. He has spent his entire career treating and studying genitourinary tumors, particularly prostate cancer. He has authored over 100 articles on the role of active surveillance in managing the disease, as well as the use of androgen deprivation with radiation and high-dose-rate radiation.

A quick review of the types of radiation therapy mentioned in this part of the discussion follows.

• Intensity-modulated radiation therapy (IMRT) allows doctors to alter the intensity of the radiation within each radiation beam, increasing radiation to the prostate while reducing its impact on normal tissues.
• Proton beam therapy uses beams of protons instead of x-rays to treat cancer. Proton therapy seems to be as precise as IMRT, but it uses a different kind of radiation.
• CyberKnife uses image guidance and computer-controlled robotics to deliver multiple beams of radiation to the tumor from almost any direction. The system tracks the tumor’s position, detects any prostate movement, and automatically adjusts the delivery of radiation.
• Permanent brachytherapy involves placing radioactive seeds in the prostate. The seeds remain in the prostate and spare, if possible, the bladder and rectum. The radioactivity level gradually dwindles to nothing.

Neither Mount Auburn Hospital nor Beth Israel Deaconess Medical Center has a proton facility. Is that something your institutions should invest in?

LAMB: Well, we have Dr. Zietman’s facility right across the river…

ZIETMAN: We do need proton facilities to treat people with certain spine and brain tumors because protons offer a clear advantage over other therapies. How many proton facilities a region needs is not clear. Unfortunately, many of the new proton facilities being built across America are not conceived to treat those in the most need. They are being built around a prostate cancer business model. This is probably not the best use of resources. Ideally, we should be learning more about protons and how best to use them, because it is not clear yet that proton beam therapy is superior to other forms of radiation therapy for the treatment of prostate cancer. It may be, but we don’t know that yet.

What financial considerations should patients keep in mind when choosing a form of radiation therapy?

ZIETMAN: You can use brachytherapy to treat prostate cancer or you can use just about any other kind of radiation therapy and probably get very similar results. The situation with protons is unique, though, because patients and vendors have been pushing it; it’s not been physician-driven.

Proton beam therapy began at Loma Linda University Medical Center in California. I’ve visited there, and it’s a magnificent place with superb patient-centered facilities. The patients are frequently highly motivated, upper-middle-class men who meet, network, and support one another. They have a very positive experience, and when they leave, they are incredibly powerful advocates for proton beam therapy. Of course, they could just as easily have had a similar experience with brachytherapy or IMRT, but they all had proton beam therapy. That’s their only frame of reference. One former patient even wrote a book about it. And through the book and the Internet, advocates of proton beam therapy have reached an enormous number of people. Many new patients who are eager to receive proton radiation come to me with the expectation that proton therapy doesn’t have any side effects at all, which just isn’t true. That’s what I mean by patient-driven.

Some of the enthusiasm is vendor-driven, at least at medical centers. It costs more than $100 million to build and equip a proton facility, but under certain contracts the vendors will now set everything up for you and collect the technical charges — the fees for all of the behind-the-scenes work and running the facility. As the physician, you collect your fee and maybe a tiny bit of the technical charge, but you and your hospital now have the prestige that comes with a showcase proton facility. Remember, there are only about five of these in the country right now.

Here’s what happens: Vendors will approach an institution and if they don’t take the bait, the vendors might say, “Well, actually we’re already speaking to your competitor down the road about a proton facility.” That may be why Oklahoma City and suburban Chicago each have two proton centers going up. If you look around the country, you’ll see that these facilities tend to go up in pairs because no hospital wants to lose its competitive edge.

I would have no problem with all of these proton facilities going up if they were dedicated to pediatrics, the treatment of tumors at the base of the skull, or for research. My problem is that most of them are rounding up the prostate cancer business. With patients getting diagnosed earlier than ever before, the pool of possible patients is growing.

What do these treatments cost?

ZIETMAN: Well, what’s billed is different from what’s reimbursed by insurance. I can give you ballpark estimates: someone getting a full course of proton beam therapy for prostate cancer is probably charged about $100,000; a full course of IMRT may be about $50,000. That would include the professional fees, all of the technical charges, and such. But the professional fees are just a tiny part of that — maybe a few thousand dollars. The rest gets collected by the institution or by the vendor who set up the treatment facility.

What’s included in the technical fees?

ZIETMAN: The cost of the machines, their upkeep, and the physicists and therapists to run them.

LAMB: Yes, there’s a team of physicists behind the scenes, and a physicist who runs the computers and determines if the machine is giving out the right amount of radiation. They do a lot of quality assurance and other things that aren’t seen but are very important. All of that is included in the technical fees.

So it’s not all profit?

ZIETMAN: For a proton facility to make a profit, it needs to treat a high number of well-insured patients. The trouble with pediatric patients and those with brain tumors is that their treatments are complex, take a long time to deliver, and are not very profitable. Prostate patients can be moved through much more quickly, hence the greater likelihood of a return on investment by treating them. The hospitals or proton facilities have the potential to line their pockets, but the physicians probably don’t. If Medicare cuts its reimbursement, it could be very difficult for proton centers to make a profit and some of the planned facilities may not succeed. If the cost of building proton facilities comes down, then the equation shifts in the opposite direction.

LAMB: In reading the article in The New York Times, I thought it was inappropriate that urologists who wanted to bill more were setting up IMRT facilities. They’re doing it for the profit, which may cause a conflict of interest.

ZIETMAN: In the early days of IMRT, radiation oncologists successfully lobbied Medicare for high reimbursements. They were able to do so because, in 2000 and 2001, it was relatively expensive to install an IMRT system, and it seemed that it would be incredibly labor-intensive. We also thought that we’d be treating only a small number of patients with IMRT.

With time, it’s become much less challenging technically and much less time-consuming. But because the reimbursement has remained high, nonspecialists have been attracted to the field. So urologists are setting up their own IMRT centers. They just buy the machine and have a radiation oncologist sign off on the dose. For me, the fact that urologists are doing the procedure instead of radiation oncologists isn’t what’s scandalous. It’s the fact that IMRT is affecting the way people practice. Patients may be offered IMRT instead of surgery, brachytherapy, or active surveillance, for example.

Because it’s more lucrative?

ZIETMAN: Yes. But that’s not a reason to push one treatment over another. You should choose a treatment for clinical reasons. Over the next five years, reimbursements for IMRT will be reduced, so the situation may change.

What about payments for brachytherapy or CyberKnife?

KAPLAN: CyberKnife is covered by Medicare, but many private insurers will not pay for it because it doesn’t have a proven track record.

ZIETMAN: Brachytherapy is starting to look like the biggest bargain around. It costs about $14,000 or so.

KAPLAN: When the brachytherapy boom started around 10 years ago, each seed cost $40 to $50. Because we use about 80 to 100 seeds during a procedure, that was a major cost. The seeds now cost less than half of that. Plus, more and more brachytherapy procedures are done in ambulatory surgery centers, where the overhead is less, so comparatively speaking, brachytherapy is a bargain.

ZIETMAN: Insurers are becoming much more aware of the fact that many patients who are older and are candidates for radiation probably don’t even need treatment, let alone an expensive treatment. So I think they are going to be looking at reimbursement rates and asking for evidence that certain procedures are cost-effective.

It’s important for our patients to understand that reimbursement practices can influence what treatments are offered.

ZIETMAN: That’s right. Reimbursement practices can restrict patients’ choices.

KAPLAN: Though it is a bit different in our practices than elsewhere. We’re all salaried. We don’t have a financial stake in a for-profit enterprise.

Should patients question a physician’s treatment recommendation? Is it appropriate for them to ask if the physician has a financial stake in a treatment?

KAPLAN: I certainly think it’s appropriate for a patient to ask why the physician is making a particular clinical recommendation. But I think that more often than not, prostate cancer patients are not going to get a single recommendation. They’re going to be presented with a range of options.

Do you ever discuss financial considerations in helping a patient choose a treatment?

ZIETMAN: I don’t. It’s not relevant to my practice.

LAMB: Patients are going to be offered all of the basic treatments, and based on side effects and logistics, there are lots of different reasons why they’ll choose one over another. For the most part, I don’t think that money is driving physicians. And if patients opt for proton beam therapy or CyberKnife as part of a clinical study in the Boston area, there’s no financial motive. We’re not at the point where there’s a proton facility on every street corner.

KAPLAN: True, but there are a lot of investment banking types going around, talking up the business model, and pushing these treatments. And there are a lot of private, for-profit radiation oncology corporations that see this as the goose that laid the golden egg. I think there are people opening IMRT centers who say, “Okay, for the next three to four years, we’re going to do really well financially. Even if we get creamed in the future with cutbacks to reimbursements, we’ll have made enough money that we’ll have paid for everything and we can get out of the business.”

What do you think the reimbursement landscape will look like in a few years?

KAPLAN: It will be data-driven. If you have a new therapy, you’ll need to prove that it works and that it’s safe in order to be reimbursed for it.

Are studies under way to help get the data?

ZIETMAN: We failed to get a consortium together to compare IMRT to protons. Some institutions don’t want to cooperate. Medicare and some insurers are hoping to initiate a study; they’re desperate to have these data.

KAPLAN: A group of physicians who use CyberKnife want to have an ongoing trial. The company is also going to sponsor a study of CyberKnife treatments, so there should be data from several dozen sites in a short time.

So what’s the “take-home” message?

KAPLAN: No aspect of prostate cancer treatment is free from controversy.

LAMB: And because prostate cancer is so controversial, it’s good to get multiple opinions. Do your due diligence. Talk to several physicians from different specialties and ask if they have a financial interest in the choice of treatments.

Originally published April 1, 2008; last reviewed April 7, 2011.