Overpriced technology in radiation oncology.

Although rising medical costs are a concern worldwide, the problem is particularly acute in the United States. Healthcare expenditures constitute about 14% of the U.S. gross domestic product (GDP), compared to 6–10% for Canada, Germany, Japan, and the United Kingdom (1). Recent projections show an increase in U.S. health care costs to about 17% of GDP by 2007 (2). When the post-World War II baby boomers start to retire in 2010, the strain on the United States economy will become particularly severe as employers, paying for rising medical costs, will be severely disadvantaged in a global economy. U.S. physicians tend to blame malpractice suits, administrative inefficiency, and fraud for the high cost of medicine. Physicians blame managed care and federal policy for diminished reimbursement. Physicians also like to point out that medicine cannot be culpable for health-care costs attributable to excessive smoking, drinking, eating, violence, sexual promiscuity, and lack of exercise. We tend to be mute, however, when faced with the accusation that healthcare costs are also being physician-driven by overinvestment in unproved technology and expensive specialists. Most physicians and medical equipment corporations have taken a responsible and sober approach to technology assessment. An aggressive minority, however, have overinvested in high-priced technology. Proton beam therapy, radiosurgery devices, remote high-dose-rate afterloading brachytherapy machines, and computer software and hardware for conformal three-dimensional treatment planning are flooding the market. Europe, North and South America, and Southeast Asia are being criss-crossed by salespersons offering their high-technology wares. For the unscrupulous minority of these salespersons, the promise to physicians and hospitals is simple: “Buy our equipment and we will organize a regional network of feeder hospitals to share in the profits of high technology radiotherapy and funnel patients to you. We will not sell our equipment to your nearby competitors and you will have a local monopoly.” The threat is also simple: “If you don’t buy equipment from us, we will sell to one of your nearby competitors. We will give them the feeder network and you will be left to wither on the vine. Here’s the price. What’s it going to be pal? I haven’t got all day.” In interstitial or intracavitary radiotherapy, it is clearly safer for health-care professionals to have the radioactive isotopes moved in and out of the catheters by a machine rather than by a physician and medical physicist. This has led to the development of remote high-dose-rate afterloading brachytherapy devices; equipment particularly useful for patients who cannot be put at bed rest for a several-day radioactive-implant procedure. Unfortunately, some radiation oncologists, in collusion with some manufacturers of these devices, have converted relatively effective conventional inpatient brachytherapy procedures into excessively fractionated outpatient high-dose-rate procedures—charging professional and technical fees for each of three to six radioactive applications with a commensurate increase in the costs. Thus, the high-dose-rate afterloader has reduced hospital inpatient days at a cost of multiple outpatient procedures. This shifts payments from hospitals to radiation oncologists—at either no change or a net increase in medical costs and no difference in tumor control or complications. Multimillion dollar radiosurgery devices were developed for the treatment of arteriovenous malformations, acoustic neuromas, functional disorders, and a selected number of localized tumors. We now find some physicians using this technology to treat multiple brain metastases to ensure that investments will return a profit in 2 years. Proton therapy facilities, priced at US $20–70 million, are being extensively used to treat prostate cancer—a highly tenuous indication (3–5). Seated in front of computer consoles, physicians are doing elaborate conformal non coplanar three-dimensional treatment plans for off-protocol treatment of patients with glioblastoma multiforme and unresectable pancreatic adenocarcinoma—pocketing hefty fees for multicolored computer printouts of therapy equivalent in efficacy to comparatively low-priced parallel-opposed photon beams. One can have a healthy scientific skepticism about technology without being a latter-day Luddite. There is unquestionably a need for improved local control of malignancies