July 08 Newsletter Articles

MEDICARE CHANGES INFLUENCED PROSTATE CANCER TREATMENT DECISIONS

Researchers are nynig to explain a major shift in prostate cancer treatment, and they are wondering whether factors other than evidence-based medicine are influencing trealment decisions. Investigators report a dramatic change from medical to surgical castration - a shift they say cannot be explained by differences in disease demographics or changes in clinical practice promoted in the literature.

The work was released online April 7 in the journal Cancer, and researchers attribute the shift to changes in Medicare reimbursement.

"It has been estimated by some that the drastic reduction in luteinizing hormone-releasing hormone agonist (LHRH-A) reimbursement actually would cause practicing physicians to lose money by administering these medications after enactment of the Medicare Modernization Act," write the authors, led by Christopher Weight, MD, from the Cleveland Clinic in Ohio.

"Certainly, changing a recommendation to a patient from a LHRH-A to surgical castration solely for economic reasons is ethically inappropriate," Gerald Chodak MD, from the Midwest Prostate and Urology Health Center in Chicago, Illinois, comments in an accompanying editorial.

"However) asking urologists to take a financial loss while treating patients also is inappropriate, even if they benefited in the past from a flaw in the reimbursement system," he noted.

Dr. Chodak explained that, as a result of a shortcoming in the Medicare reimbursement system, physicians were previously given an economic incentive to favor medical castration.

"Companies used this situation to promote their drugs and urologists benefited greatly," be writes. "At one point, LHRH-A reimbursements were the number 1 expenditure in the Medicare budget. Fortunately for the government, this problem was eventually corrected with the Medicare Modernization Act, which reduced reimbursement for these drugs by about 50%."

Dr. Weight and colleagues document a significant shift in treatment that occurred at the same time as this change. The group identified an increase in the use of orchiectomy and a simultaneow decrease in the use of all but 1 LHRH-A. The researchers found that the use of medical castration increased from 2001 to 2003; over the same period, surgical castration decreased. Total allowed charges for medical castration peaked in 2003, at $1.23 billion, and in 2005 dropped 65% from that peak.

"For many patients, this decrease may be appropriate based on the literature suggesting a tendency to overprescribe androgen deprivation for certain patients," write the investigators.

"However, there is some undefined risk that patients who would benefit from androgen deprivation may have that treatment withheld if financial pressures inhibit use."

Dr. Weight and his team believe that those with moderate or high-risk disease who might benefit from the neoadjuvant or adjuvant administration of androgen deprivation with radiotherapy are especially likely to be at risk for undenise.

The 1 product showing an increase in prescribing was the drug for which reimbursement was much less affected by the Act. This translated into a greater profit for clinicians using triptorelin pamoate, and the drug use increased by 2786.2%.

Practitioners and individuals involved in financial decisions regarding health care reimbursement should be aware that variables other than evidence based medicine and patient preference can influence treatment decisions significantly, the researchers warn.

Editorialist Dr. Chodak urges doctors to be completely honest with patients to make sure they are aware of the choices and the factors affecting a recommendation for surgery. "If enough patients find the practice unacceptable,"he writes, "perhaps they could help drive some changes."

Medscape Medical News, 11 April 2008

PROSTATE CANCER PATIENT SUPPORT 1 800 80 Us TOO

SCREENING TESTS MAY MISS PROSTATE CANCER IN OBESE PATIENTS

Higher blood volumes probably cause lower concentrations of prostatespecific antigen, or PSA, in obese prostate cancer patients, reports a study today, leading the authors to speculate that screening with PSA tests might miss some cancers in obese men.

Most U.S. prostate cancers are diagnosed by a biopsy prompted by a high PSA, the researchers write in The Journal of the American Medical Association. "The ability to accurately detect prostate cancer can be compromised by any factor that decreases PSA concentrations," they write.

The study of more than 13,000 men who had undergone prostate cancer surgery found that patients with a body mass index (BMI) of 35 or greater had PSA concentrations that were 11% to 21% lower than normal-weight patients. A 5-foot-8 man who weighs 230 pounds has a UMI of 35, which is considered moderately obese. A BMI of less than 25 is considered normal.

Obese prostate cancer patients have a higher risk of dying than normal-weight patients, says senior author Stephen Freedland, assistant professor of urology and pathology at Duke University. One reason could be that screening is missing some early cancers.

Although the link between obesity and lower PSA concentrations remains unproven in men who have not been diagnosed with prostate cancer, Freedland says, he has begun to use a 20% lower PSA cutoff when screening men whose 13M1 is 35 or higher. So instead of 4, he's using 3.2 or 3.3.

Freedland's study "just drives one more nail in the coffm of the concept that one size fits all for PSA," says Bruce Roth, a professor of medicine and urology at the Vanderbilt-Ingram Cancer Center in Nashville. Still, Roth says, it's too soon to start using a lower PSA cutoff to screen obese men. "It's hard to say what you should do in a screening population based on data only in diagnosed patients. If an obese man has no symptoms and a normal. sized prostate, lowering the PSA threshold for performing a biopsy "is stretching it a little bit"

USA Todag 23 November 2007

Radiation Reduces Mortality Risk of Recurrent Prostate Cancer

Ten-year prostate cancer survival was substantially higher for men given salvage radiotherapy alone or with hormonal therapy than for those who received no salvage therapy (86%, 82%, and 62%, respectively, P0.0001), re- ported Bruce Trock, M.D., of Johns Hopkins University, and colleagues.

The advantage extended even to those who waited for up to two years after biochemical recurrence to start radiother- apy, Dr. Track told attendees at the American Society of Clinical Oncology Genitourinary Cancers Symposium. Early salvage treatment was critical; salvage radiotherapy im- proved prostate cancer-specific survival only if given 2 years after biochemical recurrence.

Currently only about a quarter of men with biochemical recurrence receive radiation and about half are not treated, commented Howard M. Sandier, M.D., of the University of Michigan Health System in Ann Arbor, who moderated a press conference where the results were presented. "By Showing that there's a survival advantage to salvage radio- therapy, this study might increase the utilization of that par- ticular androgen strategy after surgery," he said.

When adjuvant radiation therapy is given, Dr. Trock said, it is often done immediately after their surgery for men with high-risk features because trials have shown that doing so can prolong survival. If the findings of the retrospective study are validated, it may be safe to hold off on adjuvant radiation until recurrence, Dr. Trock said. "It could eventu- ally support a way to determine who should get immediate adjuvant radiation and who could wait until the time of re- currence to have salvage therapy," he said.

However, he emphasized repeatedly, the findings were preliminary because of the retrospective nature of the study. He said a clinical trial is needed to validate the results.