Urologists Who Own Radiation Equipment Use it More … and Probably Unnecessarily

A couple of weeks ago, we wrote about urologists who, according to clinical guidelines, use too much radiation to treat prostate cancer pain. Here’s some related have-you-no-shame prostate cancer news brought to you by your local urologist.

According to a study in the New England Journal of Medicine, (NEJM) an awful lot of urologists are making decisions about treatment for their prostate cancer patients based on whether or not they own intensity-modulated radiation therapy (IMRT) facilities. One-third of men whose doctors own such equipment get that therapy for about $35,000 per treatment course. But before they were financially invested in radiation equipment, the same doctors prescribed that therapy for only 13 of 100 of their patients.

As discussed in Bloomberg Businessweek.com, prostate cancer is the most common tumor diagnosed in the U.S.; nearly 240,000 men will get a diagnosis of prostate cancer this year. As we’ve blogged often (here and here), a diagnosis of prostate cancer presents a complicated scenario; the range of appropriate treatment moves from watchful waiting (no intervention unless and until the pathology changes in certain ways) to hormone therapy to surgery, chemotherapy and radiation. As Businessweek summarizes, “While only about 12%, or 29,270 men, will die from it this year, all will have to decide how, and whether, they want to treat the cancer.”

They shouldn’t have to do so through the filter of a physician who can line his or her pockets if one therapy is chosen over another.

The men treated with radiation in the NEJM study were newly diagnosed. They were at low risk of dire consequences because their cancer hadn’t spread. The 10-year survival rate for all prostate cancer is 98%, and for many people with the study subjects’ diagnosis, watchful waiting is appropriate-not radiation.

Jean Mitchell, the author of the report and a professor of public policy at Georgetown University in Washington, D.C., compared the use of the radiation therapy among urologists before and after they acquired the $2 million machines for their practices. She studied use of the technology among doctors who didn’t own it, and urologists at 11 National Comprehensive Cancer Network centers, the country’s gold standard of care.

Analyzing claims data from Medicare, Mitchell found that urologists who didn’t own the equipment prescribed use of it for more than 15 in 100 of their patients in 2010, compared with about 14 in 100 five years earlier. Among the NCCN, the ratio was the same for both years-about 8 in 100. But among docs who began to refer patients to treatment facilities in which they had a new ownership interest, it was 44 in 100.

In an interview with Businessweek, Mitchell said, “The patients are going to do what their physician tells them to do. The patient becomes almost like an ATM machine, with the doctor extracting as much revenue as they can.”

A urologists’ association spokesman said the doctors who own radiation oncology equipment use the technology appropriately. Would you expect anything different?

As Businessweek notes, physicians aren’t allowed to refer their patients for treatment in facilities they own because of the financial conflict of interest. But for patients’ convenience, radiation, as well as some other in-office “ancillary” services such as blood work and X-rays, are exempted from that law. Why radiation, which is a treatment and not an ancillary service, was exempted is not clear, Mitchell told the news outfit.

We’ve outlined the harms of overtreatment and those of radiation. The practitioner/owner scenario has great potential to harm patients from both.

Mitchell’s study found that doctors who owned the IMRT were treating men 80 and older just as aggressively as younger men with early stage prostate cancer. While prostate cancer usually grows slowly, the side effects of radiation (erection and urinary problems, for example) can be immediate. So using this treatment on older patients opens the door for them to experience harm and no benefit.

Medicine is not immune to greed: Mitchell’s study, Businessweek notes, supports similar findings with other forms of self-referral. Some urologists have pathology labs within their practices, giving themselves more business by biopsy. We’ve noted other medical specialties with physician-owners who line their pockets primarily because they can.

If you or a loved one is diagnosed with early-stage prostate cancer, and the urologist advises radiation treatment, ask why it is appropriate; what results are expected, and how soon; what the risks are; and … who owns the facility where the treatment is recommended to occur.