Intensity-modulated Radiation Therapy Utilization Research Articles

The Association between Rural Residence and Rectal Cancer Treatment for Medicare Beneficiaries

<h3>Purpose/Objective(s)</h3> Radiation therapy and surgery are fundamental site-directed therapies for localized rectal cancer. To understand the relationship between rurality and access to specialized care, we characterized the association of rural patient residence with receipt of surgery and adjuvant radiation therapy among Medicare beneficiaries with rectal cancer. <h3>Materials/Methods</h3> We identified fee-for-service Medicare beneficiaries aged 65 or older diagnosed with non-metastatic rectal cancer from 2016 to 2018. Beneficiary place of residence was assigned to one of three categories (metropolitan, micropolitan, or small town/rural) based on census tract and corresponding Rural Urban Commuting Area codes. Multivariable regression models were used to determine associations between levels of rurality and receipt of both radiation and surgery within 180 days of diagnosis. In addition, we explored associations between patient rurality and characteristics of surgery and radiation such as minimally invasive surgery and intensity modulated radiation therapy (IMRT). <h3>Results</h3> Of 13,237 FFS Medicare beneficiaries with non-metastatic rectal cancer, 897 (6.8%) underwent both radiation and surgery within 180 days of diagnosis. For the entire rectal cancer cohort, small town/rural residence was associated with an increased likelihood of receiving both radiation and surgery within 180 days of diagnosis (Adjusted sub-hazard ratio (SHR) 1.27; 95%CI 1.07 – 1.52). Among patients who did receive surgery, no differences were observed in receipt of neoadjuvant radiation or chemoradiation based on geography. After adjustment for sociodemographic and clinical characteristics, small town/rural radiation patients were significantly less likely to receive IMRT than metropolitan radiation patients (adjusted OR 0.47, 95%CI 0.32-0.67). <h3>Conclusion</h3> Small town/rural Medicare beneficiaries were overall more likely to receive radiation treatment and surgery for their rectal cancer, but less likely to receive IMRT as part of their treatment regimen. The underlying causes for geographic variation in both standard of care surgery with radiation and IMRT utilization warrant further exploration.

Trends in IMRT Utilization for Definitive Treatment of Cervical Cancer, 2004-2018

<h3>Purpose/Objective(s)</h3> Intensity-modulated radiation therapy (IMRT) is an advanced radiotherapy technique that delivers conformal radiation to desired targets while minimizing dose to surrounding organs at risk. In the post-operative setting, IMRT is associated with reduced acute and late genitourinary and gastrointestinal side effects for patients with cervical cancer. However, no prospective randomized data exist for the use of IMRT in the setting of definitive treatment of intact cervical cancer. The objective of this study was to identify trends in IMRT use for this population. <h3>Materials/Methods</h3> Patients with stage IB2-IVA cervical cancer diagnosed from 2004-2018 who were treated with curative intent chemoradiation were identified in the National Cancer Database. Patients who underwent primary surgical management, did not receive external beam radiation to the pelvis or received radiation outside the pelvis, or received an unspecified technique or target of radiation were excluded. The primary outcome of interest was utilization of IMRT vs 3D conformal radiotherapy (3D-CRT) over time. A Cochrane-Armitage test was performed to assess trends over time. T-tests, chi-square tests, and multivariable logistic regression with propensity score matching were used to identify factors associated with receipt of IMRT. <h3>Results</h3> Overall, 13,974 patients met inclusion criteria; 4,590 (33%) received IMRT, and 9,384 (67%) received 3DCRT. In this cohort, 65% were non-Hispanic White, 45% were early stage (I-II), 80% were squamous histology, 62% received brachytherapy, and 28% had lymph node involvement. The utilization of IMRT increased from 30% in 2004 to 71% in 2018 (p<0.001). After adjustment for clinical and demographic variables, factors associated with IMRT use were: Hispanic ethnicity (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.0-1.5), treatment in the Western U.S. (aOR 1.4, CI 1.2-1.7) and the Southern U.S. (aOR 1.3, CI 1.1-1.5), living more than 50 miles from the treatment facility (aOR 1.2, CI 1.0-1.5), stage III disease (aOR 1.3, CI 1.1-1.5), and lymph node involvement (aOR 1.4, CI 1.3-1.6). Compared to an academic medical center, patients receiving care at a comprehensive community cancer center were less likely to receive IMRT (aOR 0.66, CI 0.59-0.72). There were no differences in IMRT use by age, insurance, or medical comorbidities. <h3>Conclusion</h3> Despite the lack of prospective efficacy data supporting the use of IMRT in patients with intact cervical cancer, IMRT has dramatically increased over the last fifteen years especially for patients with advanced-stage disease or lymph node involvement. More data on the optimal use of IMRT, including appropriate target volume margins and on-board imaging, are needed.

Worsening Racial Disparities in Utilization of Intensity Modulated Radiation Therapy

PurposeThe benefits of intensity modulated radiation therapy (IMRT) compared with standard 3-dimensional conformal radiation therapy have been demonstrated in many cancer sites and include decreased acute and late toxicity, improved quality of life, and opportunities for dose escalation. Limited literature suggests non-white patients may have lower utilization of IMRT. We hypothesized that as the use of IMRT has increased in recent years, racial inequities have persisted and disproportionately affect non-Hispanic Black (NHB) patients. We aim to evaluate temporal trends in IMRT utilization focusing on disparities among minoritized populations. Methods and MaterialsThe National Cancer Database was queried to identify the 10 disease sites with the highest total number of cancer patients treated with definitive intent IMRT in 2017, the most recent year for which data are available. Exclusions included stage IV, age <18 years, unknown insurance status, unknown race, and palliative intent radiation. Race and ethnicity variables were combined and classified as non-Hispanic White, Hispanic, NHB, Asian, Native American/Eskimo, and Hawaiian/Pacific Islander. Multivariable logistic regression for IMRT utilization was performed for each disease site for both early (2004-2010) and contemporary (2011-2017) cohorts, adjusting for clinical and demographic covariates. ResultsAmong the 10 selected disease sites, 1,010,292 patients received radiation therapy as part of definitive treatment between 2004 and 2017. Overall IMRT utilization rates increased from 22.0% in 2004 to 57.8% in 2017. After adjustment and compared with non-Hispanic White patients, NHB patients were significantly less likely to receive IMRT in 1 of 10 disease sites in the 2004 to 2010 cohort, and 5 of 10 disease sites in the 2011 to 2017 cohort. ConclusionsDespite greater awareness of racial disparities in cancer care and outcomes, this study demonstrates worsening disparities in the use of IMRT, particularly for NHB patients. These differences may exacerbate racial disparities in cancer outcomes; therefore, identification of underlying drivers of differential IMRT utilization is warranted.

Impact of Medicare Advantage Enrollment on Utilization of Intensity-Modulated Radiation Therapy and Cost of Care for Cancer Treatment

Intensity-modulated radiation therapy (IMRT) is an important driver of rising costs in oncology care, but the level of evidence supporting its routine use varies across disease sites, including breast, lung, and prostate. While Medicare Advantage (MA) plans have incentives to reduce health care spending, the effect of MA enrollment on utilization of high-cost medical services and quality of care is unclear, especially for cancer patients. We examined differences in IMRT utilization and health care spending between MA and traditional fee-for-service (FFS) Medicare for patients receiving radiation therapy (RT) across these disease sites. We performed a retrospective cohort study using 2009-2012 health insurance claims data from the Health Care Cost Institute (HCCI) and the Centers for Medicare and Medicaid Services (CMS). We identified 2,571 MA and 6,062 FFS Medicare beneficiaries from the HCCI and CMS databases, respectively, who were newly diagnosed with non-metastatic breast, lung, or prostate cancer in 2011 and were treated with external beam RT within 12 months of diagnosis. We measured utilization rate of IMRT, unit price of RT delivery, and RT-specific spending among patients within each cancer-type cohort. Outcomes were adjusted for differences in patient characteristics (age, sex, and Charlson co-morbidity index) and geography between MA and FFS beneficiaries. Statistical significance of the differences between groups was assessed using two-sample t tests. In both MA and FFS Medicare, the adjusted rate of IMRT utilization was highest among prostate patients and lowest among breast patients. Across all three disease sites, IMRT utilization was lower in MA than FFS Medicare, but the difference was statistically significant only for the prostate cohort (18.0 vs. 20.2%, p=0.149 for breast; 32.8 vs. 36.0%, p=0.385 for lung; 94.0 vs. 98.5%, p<0.001 for prostate). Average unit price of IMRT delivery was not significantly different in MA versus FFS Medicare. However, per patient RT-related costs were lower among MA patients in the breast and prostate cancer cohorts ($12,630 vs. $13,214 and $25,990 vs. $27,685, respectively; p=0.005 and p<0.001), but not significantly different among lung cancer patients ($15,653 vs. $15,024; p=0.301). IMRT utilization rates in both MA and FFS Medicare were consistent with the relative level of evidence supporting its use in each disease site. MA enrollment was associated with modestly lower IMRT utilization for all patients, with no evidence of a differential impact based on cancer type. The unit price of IMRT delivery was similar in MA versus FFS Medicare. We found no evidence that MA plans adopted utilization management tools that more effectively targeted high-cost therapies based on clinical evidence than in traditional Medicare.

Provider variability in intensity modulated radiation therapy utilization among Medicare beneficiaries in the United States

BackgroundIn this study, we sought to examine the variation in intensity modulated radiation therapy (IMRT) use among radiation oncology providers. Methods and materialsThe Medicare Physician and Other Supplier Public Use File was queried for radiation oncologists practicing during 2014. Healthcare Common Procedural Coding System code 77301 was designated as IMRT planning with metrics including number of total IMRT plans, rate of IMRT utilization, and number of IMRT plans per distinct beneficiary. ResultsOf 2759 radiation oncologists, the median number of total IMRT plans was 26 (mean, 33.4; standard deviation, 26.2; range, 11-321) with a median IMRT utilization rate of 36% (mean, 43%; standard deviation, 25%; range, 4% to 100%) and a median number of IMRT plans per beneficiary of 1.02 (mean, 1.07; range, 1.00-3.73). On multivariable analysis, increased IMRT utilization was associated with male sex, academic practice, technical fee billing, freestanding practice, practice in a county with 21 or more radiation oncologists, and practice in the southern United States (P < .05). The top 1% of users (28 providers) billed a mean 181 IMRT plans with an IMRT utilization rate of 66% and 1.52 IMRT plans per beneficiary. Of these 28 providers, 24 had billed technical fees, 25 practiced in freestanding clinics, and 20 practiced in the South. ConclusionsTechnical fee billing, freestanding practice, male sex, and location in the South were associated with increased IMRT use. A small group of outliers shared several common demographic and practice-based characteristics.

A Survey of Radiation Therapy Utilization in Korea from 2010 to 2016: Focusing on Use of Intensity-Modulated Radiation Therapy.

BackgroundThis study aimed to assess the recent changes of radiation therapy (RT) modalities in Korea. In particular, we focused on intensity-modulated radiation therapy (IMRT) utilization as the main index, presenting the application status of advanced RT.MethodsWe collected information from the Korean Health and Insurance Review and Assessment Service data based on the National Health Insurance Service claims and reimbursements records by using treatment codes from 2010 to 2016. We classified locating region of each institution as capital vs. non-capital areas and metropolitan vs. non-metropolitan areas to assess the regional difference in IMRT utilization in Korea.ResultsIMRT use has been steadily increased in Korea, with an annual increase estimate (AIE) of 37.9% from 2011 to 2016 (P < 0.001) resulting in IMRT being the second most common RT modality following three-dimensional conformal radiotherapy. In general, an increasing trend of IMRT utilization was observed, regardless of the region. The rate of AIE in the capital areas or metropolitan areas was higher than that in non-capital areas or non-metropolitan areas (40.7% vs. 31.9%; P < 0.001 and 39.7% vs. 29.4%; P < 0.001, respectively).DiscussionThe result of our survey showed that IMRT has become one of the most common RT modalities. IMRT is becoming popular in both metropolitan and non-metropolitan areas, while metropolitan area has faster AIE possibly due to concentration of medical resources and movement of advanced patients.

Evidence or Excess-Based? Intensity Modulated Radiation Therapy Utilization Among Elderly Patients in the United States

Evidence or Excess-Based? Intensity Modulated Radiation Therapy Utilization Among Elderly Patients in the United States

Intensity Modulated Radiation Therapy in Muscle-Invasive Bladder Cancer: Predictors of Utilization and Survival Outcomes

Prior trials of concurrent chemoradiotherapy (CCRT) for muscle-invasive bladder cancer (MIBC) utilized either two-dimensional or three-dimensional conformal radiation therapy (3DCRT) techniques. Since completion of these trials, intensity modulated radiation therapy (IMRT) has often been used in MIBC with the goal of reducing toxicity and improving the therapeutic ratio, although this has not been validated in a randomized trial. Our objective was to explore the utilization of IMRT in MIBC and to determine if there is an association between IMRT and OS in the treatment of MIBC. Patients with cT2-4 N0-3 M0 transitional cell MIBC treated with definitive doses (≥60 Gy) of RT or CCRT were selected from the National Cancer Data Base. Chi-squared test was used to compare clinical, treatment, and sociodemographic covariates between patients treated with IMRT and those treated without IMRT. Predictors associated with IMRT use were determined using a multivariable (MVA) generalized linear mixed effects model that allowed for clustering of patients within their treatment facility type. The Kaplan-Meier method was used to estimate OS, and univariate analysis (UVA) was performed using the log rank test to identify the impact of covariates on OS. MVA for OS was performed using the Cox Proportional Hazards model, and included all covariates with p<0.1 on UVA. 2,527 patients treated with radiotherapy from 2004 to 2013 met eligibility criteria; 467 (18.5%) received IMRT and 2,064 (81.4%) received non-IMRT. IMRT utilization increased over time (9.2% in 2004-2007, 27.7% in 2012-2013, p<0.0001). Patients who lived 5 to 10 miles away from their treatment facility were 43% more likely to receive IMRT than those who lived less than 5 miles from their treatment facility (OR = 1.43, 95% CI: 1.05-1.94, p =.03). Controlling for distance and year, for every 10-year increase in age, patients were 13% more likely to receive IMRT treatment (OR = 1.13, 95% CI: 1.01-1.26, p =.04). UVA revealed IMRT (p=0.03), CCRT (p<0.0001), younger age (p<0.0001), lower Charlson-Deyo comorbidity score (p<0.0001), private insurance (p<0.0001), higher median income (p=0.01), and radiation therapy dose ≥64 Gy (p<0.001) were associated with improved OS. Higher T stage (p<0.0001) and N stage (p<0.0001) were associated with decreased OS. On MVA, controlling for the other covariates in the model, patients receiving IMRT had improved OS compared to those who did not (Hazard Ratio 0.85, 95% Confidence Interval: 0.75-0.97, p=0.02). Use of IMRT has increased over time in the definitive management of MIBC. Our study is hypothesis-generating in that patients receiving IMRT in our series had improved survival compared to those who did not. This may be due to better target coverage, reduced toxicity, or due to the use of image-guidance, although further study is necessary.

Patterns of care of IMRT usage in postoperative management of uterine cancer

ObjectiveTo analyze the patterns of care regarding intensity modulated radiation therapy (IMRT) usage in the postoperative management of uterine cancer. MethodsThe National Cancer Database was queried to identify women with endometrial adenocarcinoma who underwent hysterectomy followed by external beam radiation between 2004–2012. Descriptive statistics were used to analyze IMRT usage with comparison via the Chi Square test. Overall survival was also compared between IMRT and three dimensional conformal radiation therapy. Multivariable logistic regression and multivariable Cox Regression were used to identify covariables that impact IMRT usage and improved survival respectively. Results7839 women were included in this study. IMRT utilization increased from 1.9% in 2004 to 32.4% in 2012 (p<0.001). The adjusted odds ratio (OR) for IMRT in 2012 compared with 2004 was 24.90, 95% CI 15.24–40.67 (p<0.001). Aside from year, other predictors of IMRT usage on multivariate analysis were positive nodes, higher dose, private insurance and higher income. Black race was associated with lower IMRT usage compared to Whites with an OR of 0.60, 95% CI 0.44–0.81 (p=0.001). IMRT was not associated with significantly increased survival (HR 0.86, 95% CI 0.73–1.01, p=0.06). Black race and positive nodes were associated with decreased survival within the group studied whereas private insurance and higher income were associated with improved survival. ConclusionsIn this hospital-based registry, IMRT has significantly increased in utilization for postoperative radiation in uterine cancer between 2004–2012 although not resulting in significantly improved survival. Socioeconomic and racial disparities exist in the allocation of IMRT usage.

Association of intensity-modulated radiation therapy on overall survival for patients with Hodgkin lymphoma

PurposeThe purpose of this study was to compare outcomes with Hodgkin lymphoma (HL) patients receiving IMRT (intensity-modulated radiation therapy), versus those receiving 2D/3D-CRT (3-dimensional conformal RT) in a large observational cohort. Patients and methodsWe evaluated patients diagnosed with stage I–IV HL from 1998 to 2011 from the National Cancer Database (NCDB). The association between IMRT use vs. 2D/3D-CRT, co-variables, and outcome was assessed in a Cox proportional hazards model. Propensity score (PS) matching was performed to balance known confounding factors. Survival was estimated using the Kaplan–Meier method. ResultsOf the 76,672 patients with HL within the NCDB, 12,393 patients with stage I-IV HL received RT (median dose=30.6Gy) and were eligible for this study, and 6013 patients analyzed for overall survival. The cohort had a median follow-up of 6.2years and median age of 37years (range: 18–90). The RT modalities used were: 2D/3D-CRT (n=11,491, 92.7%) or IMRT (n=902, 7.3%). Patients were more likely to receive IMRT if they were of male gender, early stage, no “B” symptoms, and treated at comprehensive cancer programs (all p<0.05). During this time period, there was a significant decrease in use of 2D/3D-CRT from 100% to 81.5%, with a subsequent increase in IMRT utilization from 0% to 18.5%. Five-year overall survival for patients receiving 2D/3D-CRT (n=5844) was 89.9% versus 95.2% for those receiving IMRT (n=169; HR=0.45; 95% CI, 0.23–0.91, p=0.02). After PS-matching based on clinicopathologic characteristics, IMRT use remained associated with improved overall survival (HR=0.40; 95% CI, 0.16–0.97, p=0.04). ConclusionsOur study reveals that HL patients receiving modern RT techniques were associated with an improvement in overall survival. This may have been related to patient selection, access to improved staging and management, or improvements in treatment technology. This represents the only study examining survival outcomes of advanced RT modalities, which may be considered on a case-by-case basis for highly selected patients with HL.

IMRT utilization in Ontario: qualitative deployment evaluation.

The purpose of this paper is to describe a jurisdiction-wide implementation and evaluation of intensity-modulated radiation therapy (IMRT) in Ontario, Canada, highlighting innovative strategies and lessons learned. To obtain an accurate provincial representation, six cancer centres were chosen (based on their IMRT utilization, geography, population, academic affiliation and size) for an in-depth evaluation. At each cancer centre semi-structured, key informant interviews were conducted with senior administrators. An electronic survey, consisting of 40 questions, was also developed and distributed to all cancer centres in Ontario. In total, 21 respondents participated in the interviews and a total of 266 electronic surveys were returned. Funding allocation, guidelines and utilization targets, expert coaching and educational activities were identified as effective implementation strategies. The implementation allowed for hands-on training, an exchange of knowledge and expertise and the sharing of responsibility. Future implementation initiatives could be improved by creating stronger avenues for clear, continuing and comprehensive communication at all stages to increase awareness, garner support and encourage participation and encouraging expert-based coaching. IMRT utilization for has increased without affecting wait times or safety (from fiscal year 2008/2009 to 2012/2013 absolute increased change: prostate 46, thyroid 36, head and neck 29, sarcoma 30, and CNS 32 per cent). This multifaceted, jurisdiction-wide approach has been successful in implementing guideline recommended IMRT into standard practice. The expert based coaching initiative, in particular presents a novel training approach for those who are implementing complex techniques. This paper will be of interest to those exploring ways to fund, implement and sustain complex and evolving technologies.

Intensity Modulated Radiation Therapy Utilization in the Treatment of Gastrointestinal Malignancies Between 2000 and 2009 in the SEER-Medicare Population

Intensity modulated radiation therapy (IMRT) is a novel approach to radiation treatment planning and delivery. Numerous dosimetric studies in gastrointestinal (GI) malignancies have shown that the integration of IMRT is feasible and, when compared with conventional radiation therapy approaches, results in improved normal tissue sparing. Retrospective comparisons have demonstrated improvements in acute and late toxicity rates with selected studies demonstrating superior treatment outcomes with IMRT.

Collaborating with Ontario cancer centers to ensure coordinated access to safe, evidence-based, high-quality IMRT treatment.

187 Background: In 2007, CCO identified variability in access to Intensity Modulated Radiation Therapy (IMRT) across the province. To ensure access to this technology, a three-year IMRT implementation Project was started in 2008, focusing on the development of: disease site guidelines and targets, cost-effectiveness analyses, a provincial quality assurance program, disease and discipline specific communities of practice and knowledge-sharing platforms. Methods: Needs assessments were conducted to identify educational and training needs in all disciplines. Systematic reviews were undertaken to establish disease site specific IMRT indications, set targets and conduct cost effective analyses. Educational courses and hands on expert-based coaching, were made available and a provincial IMRT quality assurance program was established. Results: The needs assessments identified a strong interest in educational and coaching opportunities. IMRT indication guidelines were developed for 10 disease sites and utilization targets were set for 6 disease sites. Results from two cost effectiveness analyses confirmed IMRT as a standard of care over 3D Conformal Radiation Therapy. 11 cancer centres received IMRT expert-based coaching, which included hands on-training, site visits, and educational support. Knowledge sharing and educational opportunities were provided to over 949 radiation therapists, oncologists and physicists. 13 cancer centres participated in external IMRT quality assurance testing for head and neck and prostate cancer. IMRT utilization has increased without affecting wait times or patient safety with no increase in incidents during this time period. All six disease sites have me their targets for 2012/13. Conclusions: IMRT knowledge and expertise across the province has grown along with a dramatic increase in the percentage of patients being treated for curative intent receiving IMRT. This jurisdictional implementation project was successful in making this treatment available to all Ontarians who would benefit. The lessons learned from this experience may be useful in the future rollout of other new technologies in Ontario and in other health care settings.

Variation in the use of intensity-modulated radiation therapy (IMRT) in the state of Michigan: 2005-2010.

219 Background: Interest is growing in value in health care, defined as better outcomes at lower costs. A primary driver of cost in radiation oncology is the use of IMRT. We examined the patterns and correlates of use of IMRT across Michigan using publicly available data. Methods: As a certificate of need state, Michigan requires every radiation oncology facility to report yearly the number of external beam and IMRT treatments delivered. Data for 2005-2008 were obtained through a Freedom of Information Act request of the Michigan Department of Community Health, while 2009-2010 data were available at its website. Percentage of external beam treatments delivered using IMRT (IMRT%) was examined across centers over time and repeated-measures longitudinal linear regression was used to identify factors associated with use. Results: During 2005-2010, 48 to 65 centers reported data. Median IMRT% (range) rose steadily during the study period: 2005 16% (0-64); 2006 21% (0-57); 2007 27% (0-79); 2008 37% (7-85); 2009 41% (0-87) 2010 45% (7-100). There was also significant between-center variation (see table). Regression modeling demonstrated that IMRT% was associated with year (+6.7% per year, p&lt;0.0001), facility type (+7.1% freestanding versus hospital, p&lt;0.11), facility annual volume (+5.0% high volume: 7,000+ versus low: &lt;7,000, p=0.01) and the interaction between year and volume (low volume +2.4% per year versus high volume p&lt;0.02). The significant interaction between year and volume suggests that the greatest IMRT% growth was in low volume centers (6.7% per year versus 4.3% per year for high volume). Conclusions: IMRT utilization has grown steadily across Michigan between 2005 and 2010. There is significant variation in its use that appears to be related in part to facility characteristics. The newly established Michigan Radiation Oncology Quality Collaborative (MROQC) is beginning to explore the use of IMRT in patients with breast and lung cancer statewide to identify those groups of patients where improved outcomes may justify its higher cost. [Table: see text]

Rational use of intensity-modulated radiation therapy (IMRT) as determined by radiation oncologists in cooperation with Blue Cross Blue Shield of Massachusetts (BCBSMA).

73 Background: IMRT is a sophisticated radiation technique that allows more precise delivery than conventional external beam radiation (EBRT). Prospective randomized data indicating which patients are most likely to benefit from IMRT are limited, and the rate of IMRT utilization varies widely. Methods: BCBSMA reached out to radiation oncologists to develop a consensus regarding the use of IMRT. Initial discussions started in 2009. The process included discussions within radiation oncology departments and meetings and conference calls with BCBSMA. In April 2011 a survey was sent to radiation oncologists, followed by the formation of a Physician Advisory Council consisting of representatives of 11 large academic and private practices. The council met in June 2011 and continued to develop guidelines over a series of conference calls. Results: The BCBSMA IMRT policies went into effect on 9/1/11. No policies for the use of EBRT were created. It was agreed that IMRT is appropriate for cancers of the head and neck, prostate, and anus. For other sites, emphasis was placed on the QUANTEC recommendations regarding acceptable doses to normal tissues. To justify the use of IMRT, radiation oncologists were asked to demonstrate that conventional EBRT resulted in excess dose to normal tissues, and that IMRT could lower the doses to an acceptable range. In addition, a process was set up for peer-to-peer review to consider the application of IMRT to cases outside of the guidelines. Preliminary analysis of claims compared the case rat /1,000 BCBSMA members over a 6 month pre-IMRT policy implementation base period to a 6 month post-implementation case rate. The number of IMRT cases during the study period was decreased by 20% while the EBRT cases/1,000 members during the study period increased by 14%. During the two prior years, the IMRT cases/1,000 members for IMRT increased 20%, while the EBRT cases/1000 members decreased 3%. Conclusions: The experience in Massachusetts suggests that practicing physicians and insurers can work together to achieve a consensus regarding the appropriate application of high-technology treatments potentially impacting their rate of utilization.

IMRT for Breast Cancer—Balancing Outcomes, Patient Selection, and Resource Utilization

Over the past decade, there has been a rapid rise in the utilization of advanced radiation delivery technologies for the intended curative management of many solid cancers. For breast cancer, radiation practice patterns have shifted from conventional twodimensional therapy based on fluoroscopy and bony anatomy to a more refined three-dimensional approach utilizing computed tomography planning. Three-dimensional radiation provides the oncologist with precise information concerning the radiation dose to all areas of the affected breast, regional nodes, and adjacent normal tissues and therefore may offer reduced morbidity and improved long-term breast cosmesis, whereas maintaining local tumor control. The current question is whether further improvements in target dose coverage and normal organ sparing, both of which are provided by a more advanced form of radiation delivery called intensity-modulated radiation therapy (IMRT), produce a measurable improvement in treatment outcomes over three-dimensional radiation delivery. In this issue of the Journal, Smith et al. (1) report on the increased use of IMRT for the adjuvant therapy of breast cancer in the United States. Improvements in radiation-induced morbidity have been described in patients with head and neck and prostate cancers treated with IMRT (2,3). Small randomized studies in early-stage breast cancer also suggest that a reduction in acute toxicity can be achieved (4–6). However, in this era of rapidly evolving radiation technology, there is a concern that IMRT is being widely implemented without evidence-based knowledge of its effects on long-term efficacy and morbidity. Moreover, IMRT is associated with a substantially greater cost to the patient (or insurance company) because of the increased physician and physicist workload to generate IMRT plans and provide the necessary quality assurance for such plans. With the recent emphasis on cost-effective quality care in the Unites States, we must understand the potential benefits of this new technology and balance them with an appropriate selection of patients, as well as best use of resources, before IMRT can be adopted for the adjuvant management of breast or other cancers. Smith et al. (1) analyzed Surveillance Epidemiology and End Results–Medicare records of care and outcomes for 26 163 women aged 66 years or older who were treated with surgery and adjuvant radiation for nonmetastatic breast cancer between 2001 and 2005. They found that in 2001, there was a prevalence of IMRT use of 0.9%, which rose to 11.2% by 2005, reflecting a greater than 10-fold increase in use for a potentially large population of patients. Notably, the use of IMRT more than doubled the cost of radiation treatment, and the overall cost of treatment increased by more than 30% during this 5-year period. Unfortunately, these data do not provide insight into potential clinical scenarios in which IMRT may improve treatment results and perhaps justify its increased cost. Tumor characteristics were not strongly associated with an increased use of IMRT, suggesting that it was not being adopted to address a perceived medical concern. Even the higher prevalence of using IMRT for left-sided breast cancers (where there is concern over the radiation dose to the underlying lung and heart) was only 6.5%, as compared with 5.5% on the right. Notably, what we do learn from Smith et al (1) is that the largest increase in IMRT utilization is in regions where Medicare pays for it. As such, the major conclusion from the analysis is that IMRT is being adopted for the adjuvant management of localized breast cancer within areas of the Unites States where it is reimbursed. This conclusion would appear to confirm the suspicion of many, both within and outside of the healthcare industry, that medical

Cost Implications of the Rapid Adoption of Newer Technologies for Treating Prostate Cancer

Intensity-modulated radiation therapy (IMRT) and laparoscopic or robotic minimally invasive radical prostatectomy (MIRP) are costlier alternatives to three-dimensional conformal radiation therapy (3D-CRT) and open radical prostatectomy for treating prostate cancer. We assessed temporal trends in their utilization and their impact on national health care spending. Using Surveillance, Epidemiology, and End Results-Medicare linked data, we determined treatment patterns for 45,636 men age ≥ 65 years who received definitive surgery or radiation for localized prostate cancer diagnosed from 2002 to 2005. Costs attributable to prostate cancer care were the difference in Medicare payments in the year after versus the year before diagnosis. Patients received surgery (26%), external RT (38%), or brachytherapy with or without RT (36%). Among surgical patients, MIRP utilization increased substantially (1.5% among 2002 diagnoses v 28.7% among 2005 diagnoses, P < .001). For RT, IMRT utilization increased substantially (28.7% v 81.7%; P < .001) and for men receiving brachytherapy, supplemental IMRT increased significantly (8.5% v 31.1%; P < .001). The mean incremental cost of IMRT versus 3D-CRT was $10,986 (in 2008 dollars); of brachytherapy plus IMRT versus brachytherapy plus 3D-CRT was $10,789; of MIRP versus open RP was $293. Extrapolating these figures to the total US population results in excess spending of $282 million for IMRT, $59 million for brachytherapy plus IMRT, and $4 million for MIRP, compared to less costly alternatives for men diagnosed in 2005. Costlier prostate cancer therapies were rapidly and widely adopted, resulting in additional national spending of more than $350 million among men diagnosed in 2005 and suggesting the need for comparative effectiveness research to weigh their costs against their benefits.

491 TIME TRENDS IN THE UTILIZATION OF HIGHER-COST TREATMENTS FOR PROSTATE CANCER, 2002-2007

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II1 Apr 2010491 TIME TRENDS IN THE UTILIZATION OF HIGHER-COST TREATMENTS FOR PROSTATE CANCER, 2002-2007 Wesley Choi, Paul Nguyen, Xiangmei Gu, Stuart Lipsitz, Toni Choueiri, Yin Lei, Anthony D'Amico, and Jim Hu Wesley ChoiWesley Choi More articles by this author , Paul NguyenPaul Nguyen More articles by this author , Xiangmei GuXiangmei Gu More articles by this author , Stuart LipsitzStuart Lipsitz More articles by this author , Toni ChoueiriToni Choueiri More articles by this author , Yin LeiYin Lei More articles by this author , Anthony D'AmicoAnthony D'Amico More articles by this author , and Jim HuJim Hu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.566AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess temporal trends in the use of higher-cost therapies for non-metastatic prostate cancer (PCa) in the US from 2002-2007 METHODS We determined treatment patterns for 58,581 men aged ≥65 years diagnosed with non-metastatic PCa from 2002-2005 and treated through 2007 using Surveillance, Epidemiology, and End-Results (SEER) –Medicare linked data. Current Procedural Terminology 4th edition (CPT-4) codes were used to distinguish intensity-modulated radiation therapy (IMRT) vs. standard conformal beam radiation, and between minimally-invasive radical prostatectomy (MIRP) vs. open prostatectomy. Annual trends were compared with the Mantel-Haenszel trend test. RESULTS Treatment rates for cancer diagnosed in 2002 vs. 2005 were as follows: external radiation (29.8% vs 29.4%, p=0.33), surgery (18.9% vs. 21.5%, p<0.001), brachytherapy (15.5 vs. 16.0%, p=0.28), primary androgen deprivation therapy (20.5% vs 16.5%, p<0.001), and cryotherapy (1.3% vs. 3.0%, p<0.001). For surgery, the utilization of MIRP increased substantially over time (9.5% vs 28.7%, p<0.001), and for external radiation, IMRT utilization increased substantially (28.7% vs. 81.7%, p<0.001). Men receiving IMRT vs. standard radiation were more likely to live in areas with >90% high-school graduates (40.1% vs. 29.0%, p<0.001), with median annual income '$60,000 (20.9% vs. 12.3%, p<0.001), reside in the Northeast or West (72.1% vs. 69.2%, p=0.017), and were more likely to be non-white (23.5% vs. 22.1%, p=0.03). Men receiving MIRP vs. open prostatectomy were more likely to reside in areas with >90% high-school graduates (50.1% vs. 40.1%, p<0.001), with median annual income ≥$60,000 (35.4% vs. 21.1%, p<0.001), and live in the Northeast or West (72.1% vs. 69.2%, p=0.017). CONCLUSIONS Shifts in the relative use of surgery, radiation, and brachytherapy for prostate cancer were generally minor, but within surgery and radiation, use of higher-cost therapies increased dramatically despite limited comparative effectiveness outcomes assessment. Utilization of these higher cost therapies was more likely to occur in areas with >90% high school education, median annual income of ≥$60,000, and in the Northeast or West. Boston, MA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e194 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wesley Choi More articles by this author Paul Nguyen More articles by this author Xiangmei Gu More articles by this author Stuart Lipsitz More articles by this author Toni Choueiri More articles by this author Yin Lei More articles by this author Anthony D'Amico More articles by this author Jim Hu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...