December 1, 2006
SIDE EFFECTS
Profit and Questions on Prostate Cancer Therapy
By STEPHANIE SAUL
The nearly 240,000 men in the United States who will learn they have
prostate cancer this year have one more thing to worry about: Are their
doctors making treatment decisions on the basis of money as much as
medicine?
Among several widely used treatments for prostate cancer, one stands out
for its profit potential. The approach, a radiation therapy known as
I.M.R.T., can mean reimbursement of $47,000 or more a patient.
That is many times the fees that urologists make on other accepted
treatments for the disease, which include surgery and radioactive seed
implants. And it may help explain why urologists have started buying
multimillion-dollar I.M.R.T. equipment and software, and why many more
are investigating it as a way to increase their incomes.
Already, dozens of the nation's 10,000 urologists have purchased the
technology for intensity modulated radiation therapy, which is what
I.M.R.T. stands for, and some of them are recommending its use for
growing numbers of their patients.
Critics see a potential conflict of interest on the part of urologists,
the specialists who typically help prostate patients choose a course of
treatment. The critics say that urologists who can profit from the new
form of therapy may be less likely to recommend other proven approaches,
which for some older men can involve forgoing treatment altogether.
If the patient has insurance, the added expense may not be a concern for
him. And like the other treatments, the new therapy can be highly
effective. But doctors say that prostate cancer treatments should be
tailored to the individual.
Compared with seed implants, for example, I.M.R.T. involves a large time
commitment, requiring patients to visit a radiation center 45 times over
the course of nine weeks.
More worrisome for some experts is a concern that the multiple-beam
radiation of I.M.R.T. may raise the risk of secondary cancers, although
no medical studies have proved such a link.
Helping drive the trend is a Texas company, Urorad Healthcare, which
sells complete packages of I.M.R.T. technology and services, and hopes
to persuade even more urologists to buy them.
"Join the Urorad team and let us show your group how Urorad clients
double their practice's revenue," the company says in a marketing pitch
to doctors on its Web site.
Urologists who have purchased the new multiple beam systems say they are
embracing a superior way to treat prostate cancer. But because there is
little research directly comparing I.M.R.T. with the other treatments,
there is little consensus among urologists about which approach is best.
That is why some doctors worry that I.M.R.T. may be emerging as yet
another example of the way financial incentives can influence medical
decisions in this nation's for-profit health care economy.
"It's all money-driven, and it's a shame medicine has come down to
this," said Dr. Brian Moran, a radiation oncologist in Chicago, who
specializes in radioactive-seed implants, in which tiny radioactive
pellets are placed into the prostate. His clinic is paid $15,000 or less
for the procedure, with the urologist on the case getting about $900.
Dr. Eli Glatstein, a professor of radiation oncology at the University
of Pennsylvania, said he was concerned that some urologists would steer
patients to the new treatment because they owned the technology and
could greatly profit from its use.
"It's not illegal to do this," Dr. Glatstein said. "That doesn't make it
right."
I.M.R.T. was introduced in the mid-1990s and has proved useful for
delivering multiple beams of radiation to a small area while avoiding
healthy tissue. Like other treatments for prostate cancer, though, it
has possible side effects, potentially including impotence.
The one certainty about I.M.R.T. is that for doctors who own the
technology, it can be much more lucrative than alternative treatments.
Medicare and other insurers typically pay urologists only $2,000 or less
for performing surgery to remove the prostate or for implanting
radioactive seeds. The insurers say the much higher I.M.R.T. payments,
which in some cases exceed $50,000, are based on the technology's cost.
Leslie Norwalk, Medicare's chief administrator, said she was not worried
that doctors who invest in I.M.R.T. would use it on patients who require
no treatment.
"You're just not going to do beam therapy on someone who doesn't need
it," Ms. Norwalk said in a telephone interview.
But because of the potential conflicts, urologist-owned I.M.R.T. is the
type of arrangement that Medicare should be watching, she said.
Dr. Juan A. Reyna, president of a San Antonio urology group that was
among the first to order I.M.R.T. technology in 2004, said that the
revenue opportunities were a factor in the decision to buy it.
"These are the kind of things you have to do to be able to maintain
yourself in practice," Dr. Reyna said, noting that Medicare has been
cutting back payments for other forms of prostate cancer treatment. Dr.
Reyna says he recommends the treatment more frequently now because he is
convinced of its value.
Some other urologists, though, say they are uncomfortable with the
I.M.R.T. ownership trend. For example, Dr. Robert Waldbaum of Manhasset,
N.Y., said he declined to go along when a large group of Long Island
urologists invested in the technology, fearing it might influence his
advice to patients.
"I felt in my own mind that it would be a conflict of interest to me,"
said Dr. Waldbaum, the former chairman of urology at North Shore
University Hospital, who is in private practice.
Varian Medical Systems, a leading maker of the technology, still sells
it mainly to hospitals and free-standing radiation oncology centers. But
it has sold about 20 I.M.R.T.-capable machines to urology groups,
according to a company spokesman, Spencer Sias. Typically, doctor groups
pool their money to buy the technology.
"There's definitely heightened interest from urology practices in this,"
Mr. Sias said.
Helping drive that interest is Urorad, based in McAllen, Tex., which has
been aggressively marketing I.M.R.T. to urologists across the country,
who must either hire a radiation oncologist or form a partnership with
one. The company helps arrange a complete setup as well as consulting
services to calculate radiation doses for patients, with costs to get
started estimated at about $3 million.
Five Urorad centers are already operating around the country, according
to Dr. Mark L. Harrison, the chief executive, who said that contracts
had been signed for six more.
The majority of prostate cancers are caught early, owing mainly to use
of the prostate-specific antigen test. Still, prostate cancer is the
second-leading cause of cancer-related deaths in men, after lung cancer.
The prostate cancers that are detected early have several treatment
alternatives with high success rates — among them surgery, radioactive
seed implants, and external radiation, like the multiple beam therapy.
In some cases, especially for older men, doctors recommend "watchful
waiting," or no treatment at all. An estimated 40 percent to 50 percent
of men with the disease get surgery, which many doctors still consider
the gold standard for a cure. But surgery also carries a risk of
incontinence; up to 29 percent of men who have their prostates removed
report wearing pads to keep dry, according to one large study.
As with surgery and seed implants, men treated with I.M.R.T. run a risk
of eventual impotence. A recent study at Memorial Sloan-Kettering Cancer
Center, which has conducted much of the early research on the therapy,
found that eight years after treatment, 49 percent of men who were
potent before treatment developed erectile dysfunction.
Compared with surgery, neither seed implants nor I.M.R.T. carry high
risks of incontinence, though. And the arguments in favor of the
multiple beam therapy include a new research study indicating that
urinary complications, like painful urination and a narrowing of the
urethra, are lower with I.M.R.T. than with seed implants.
Depending on the region of the country, the owner of an office-based
I.M.R.T. system can be reimbursed up to $47,000 for a nine-week course
of daily treatments, including the physician's fee, which often goes to
the radiation oncologist.
Medicare and commercial insurers have said the reimbursements are based
not only on the cost of the software and equipment, but on the
complicated mathematical calculations required in administering the
treatments.
Yet Dr. Ivan A. Brezovich, a physicist at the University of Alabama at
Birmingham, said that delivering multiple beam therapy to the prostate
was a relatively simple procedure compared with using it on more complex
conditions like head and neck cancers.
"You can do it almost on an assembly-line basis," Dr. Brezovich said.
Medicare, which has reviewed the issue, is scheduled to begin reducing
I.M.R.T. reimbursements. For example, reimbursement in the Atlanta area,
considered close to the national median, is scheduled to be cut by 8.2
percent, from $39,000 this year to $35,800 in 2007.
But because Medicare or another insurer pays for the treatment, cost is
often not a factor for patients as they assess their options.
Leonard Streim, 58, a clinical psychologist in Deer Park, N.Y., learned
he had prostate cancer this year. He said he researched various options,
including seed implants and surgery, before deciding on multiple beam
treatment, which was covered by his medical insurance.
Mr. Streim said his side effects were minimal.
"As compared to surgery, as compared to walking around being
radioactive, I don't think there's any choice there, at least not for
me," he said.
His urologist is a member of a large Long Island group, Integrated
Medical Professionals, formed in July by 13 different practices with a
total of more than 30 doctors. Now the largest urology group on Long
Island, it pooled its resources to invest in an image-guided I.M.R.T.
system, which uses markers implanted in the prostate to more accurately
direct the beams of radiation. Some say that the group's formation has
contributed to a shift in prostate cancer treatment in the region.
Fewer patients in the area now appear to be getting seed implants,
according to Dr. Jay Bosworth, a radiation oncologist involved with
another Long Island group of diagnostic and treatment centers whose
services include I.M.R.T.
According to three hospitals where doctors in the Integrated Medical
Professionals group have practiced, about 300 seed procedures were
performed in 2005 compared with about 100 this year through mid-October.
Dr. Deepak A. Kapoor, Integrated Medical's chief executive, said the
downturn in seed implants began before his group's formation, as
urologists began to recognize the benefits of I.M.R.T. He denied that
financial incentives were a driving force.
"All of our physicians are required to discuss all available options
with every patient," Dr. Kapoor said.
One of Dr. Kapoor's Long Island patients, Daniel Staiano of Massapequa,
N.Y., who is covered by Medicare, said he was not concerned to learn
that his urologist had a financial stake in the therapy.
Mr. Staiano, 75, was one of several patients treated by I.M.R.T. in
Plainview, N.Y., who said they suffered only minor side effects after
the nine-week course of radiation.
"This treatment is fabulous," said Mr. Staiano, a retired tape editor
for NBC, who said that his side effects were minimal. "If I ever get
cancer again," he said, "this is the way I want to go