Expanding Utilization of Intensity-Modulated Radiotherapy for Prostate Cancer: Soaring Costs, Dubious Benefits: Comment on “Comparative Effectiveness of Intensity-Modulated Radiotherapy and Conventional Conformal Radiotherapy in the Treatment of Prostate Cancer After Radical Prostatectomy”

noma of the prostate: long-term results from Proton Radiation Oncology Group/ American College of Radiology 95-09. J Clin Oncol. 2010;28(7):1106- Pollack A, Zagars GK, Starkschall G, et al. Prostate cancer radiation dose re- sponse: results of the M. D. Anderson phase III randomized trial. Int J Radiat Oncol Biol Phys. 2002;53(5):1097-1105. Koontz BF, Das S, Temple K, et al. Dosimetric and radiobiologic comparison of 3D conformal versus intensity modulated planning techniques for prostate bed radiotherapy. Med Dosim. 2009;34(3):256-260. Digesu C, Cilla S, De Gaetano A, et al. Postoperative intensity modulated radia- tion therapy in high risk prostate cancer: a dosimetric comparison. Med Dosim. Pinkawa M, Siluschek J, Gagel B, et al. Postoperative radiotherapy for prostate cancer: evaluation of target motion and treatment techniques (intensity- modulated versus conformal radiotherapy). Strahlenther Onkol. 2007;183(1): Goenka A, Magsanoc JM, Pei X, et al. 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INVITED COMMENTARY Expanding Utilization of Intensity-Modulated Radiotherapy for Prostate Cancer Soaring Costs, Dubious Benefits P rostate cancer in the United States is character- ized by a unique epidemiology: a prevalence un- rivaled by any other visceral malignant neo- plasm among men and a prolonged natural history often measurable in decades rather than years. Early detec- tion and aggressive management of higher-risk prostate cancer explain a substantial proportion of the more than 40% drop in prostate cancer mortality rates observed since the 1990s. 1 The price of this remarkable success, how- ever, has been high rates of avoidable overtreatment of both newly diagnosed and recurrent prostate cancer, with excessive attendant morbidity and cost. Reflecting both screening of asymptomatic men and increasingly inten- sive surveillance (eg, with ultrasensitive prostate- specific antigen [PSA] tests, more extensive biopsies, and growing use of advanced imaging) of those treated, men are receiving both primary and salvage treatments at younger ages and earlier in the natural history of the dis- ease. Reducing the potential morbidity of these treat- ments remains one of the central goals of prostate can- cer clinical research. The recent evolution of management options for lo- calized prostate cancer largely reflects the advent of 2 tech- nologies: robot-assisted laparoscopic surgery and intensity- modulated radiotherapy (IMRT). The promulgation of these 2 treatment platforms for prostate cancer has been in many respects parallel: both have been marketed ag- gressively and widely adopted based on relatively lim- ited and sometimes contradictory data. The growth of IMRT has been particularly explosive: IMRT accounted for 0.15% of external-beam radiotherapy treatments in 2000 and 95.9% in 2008. 2 In general, IMRT is associ- ated with lower toxicity than conventional 3D confor- mal radiotherapy (CRT), although the benefits are fairly modest, and at least one analysis 2 found greater sexual dysfunction after IMRT than after CRT. External-beam radiation also may be combined with brachytherapy, and following radical prostatectomy— whether open or robot-assisted—it may be adminis- tered to men with high-risk pathology and/or persistent or recurrent PSA as adjuvant or salvage therapy. Recent trials generally support a greater role for postoperative radiotherapy, and utilization of this combination of sur- gery with radiotherapy may be expected to increase, par- ticularly for men with higher-risk disease. 3 Although at least some evidence exists to support the use of IMRT over CRT for primary monotherapy of prostate cancer, data for its use in these other contexts are essentially ab- sent. For combination brachytherapy with external ra- diation, IMRT utilization nearly quadrupled in 3 years— from 8.5% in 2002 to 31.1% in 2005, with no published studies suggesting a benefit in this setting. Goldin et al 4 used Medicare data to examine trends and outcomes for radiation given as adjuvant or salvage therapy after prostatectomy. The authors found that here, as in other settings, IMRT has rapidly overtaken CRT as the dominant radiation modality, rising from zero cases in 2000 to 82.1% of cases in 2009. Once again, there were no observed benefits—in terms of either cancer control or any quality-of-life domain—observed for IMRT vs CRT. Important caveats to this analysis should be noted. Aside from the fact that Medicare only enrolls men older than 65 years, the Centers for Medicare & Medicaid Services data files only include men in Medicare fee-for-service. Indeed, more than 61% of the potential sample was excluded either for the availability of less than 1 year of preradiotherapy claims data and/or for discontinuous fee-for-service en- rollment. How representative the remaining men are of the broader population of men with prostate cancer is unclear because there are likely important differences between those enrolling in managed care plans and those choosing to re- main in fee-for-service. As more Medicare participants en- JAMA INTERN MED/ VOL 173 (NO. 12), JUNE 24, 2013 WWW.JAMAINTERNALMED.COM ©2013 American Medical Association. All rights reserved. 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