JAMA - IMRT vs 3D for adjuvant RT in prostate cancer

[deleted4401]

http://archinte.jamanetwork.com/article.aspx?articleid=1689975

Can't open the full article. Not really surprised with results, except that if they didn't account for dose, that might explain why toxicity is the same (thinking that people treated with IMRT were treated to a higher dose). And, it says "cancer control" but the outcome seems to be further treatment, not PSA control. It's already on the health care policy blogs...

S

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[napoleondynamite]

I'm sure this will create a policy buzz..

 

[seper]

Another well done study using linked SEER-Medicare data.

IMHO, IMRT is now so widely used for almost every definitive treatment site, that it'll take people reporting worse outcomes with IMRT to shift practice back to 3D-CRT.

 

[deleted4401]

What I tried to explain to on blog...

Essentially, IMRT is theoretically better, and dosimetrically better. If I was a patient, I'd want IMRT. However, I don't think it is worth the extra money. I think the reimbursement should be reflective of effort, and currently the reimbursement is disproportionately higher for a treatment that isn't shown to be better. To me, this is like a surgical technique that had some volume of blood loss that is better than the older technique. It's not going to have any clinical outcome that's better. It's just better because its cleaner. I don't think I should be paid higher for it. But, it's the technique I prefer. If Medicare wants to adjust it and pay us less for it because there isn't any data for it, I'm okay with that. But it doesn't mean I want to stop using it. I have 2 knives in the kitchen. Both make great lamb curry. One takes marginally less time, but not enough less time to watch a sitcom, sometimes in fact the better knife takes longer because I end up talking on the phone while cutting, because it cuts so damn good. But, I love that knife and will keep using it. Even though it's not proven to better, I know it is. I'm willing to pay more for it. I'll eat the cost (I.e. take 3D reimbursement for IMRT treatment) because I know it's better.

Blogger proceeded to show 10 RCTs in general medicine that were theoretically better, but no benefits were borne out in RCTs,

http://theincidentaleconomist.com/wordpress/more-comparative-effectiveness-goodness/

If you care about health policy, this is probably the best one out there, especially if you believe in evidence based medicine. They are fanatics about it, but I think they don't understand oncology all that well. Ezra Klein's wonkblog is good, but it's not all health care.

Any other takes?
S

 

[radiadouken]

What I tried to explain to on blog...
To me, this is like a surgical technique that had some volume of blood loss that is better than the older technique. It's not going to have any clinical outcome that's better. It's just better because its cleaner.
S

This sort of argument is often made for robotic prostatectomy. Less blood loss, shorter hospitalization. But even those are quantifiable differences in patient care/experience. I think it's harder to make an argument for IMRT if there is no quantifiable metric (other than dosimetric planning), right?

 

[radiaterMike]

What is missing from arguments here and on SimulD postings on the blog is that this is a retrospective study with no dosimetric data. While many patients (perhaps most) would be treated with 3DRT or IMRT based upon institutional or MD policy, many may have been selected for IMRT because the IMRT plan yielded an anticipated meaningful clinical benefit. Likewise, some may have been chosen to receive 3DRT because IMRT was not expected to yield much benefit. Not all post-prostatectomy fields are the same (some treat more superiorly in the pelvis). So - there are some patients in the IMRT group which will have been expected to experience more toxicity with 3D- hence taking them out of the 3D group and into the IMRT group. Also- the study is not designed to look at acute toxicity- which has been correlated with small bowel dose.

 

[deleted4401]

Yeah. It's going to be tough if all those programs for CER get funded. How to show clinical benefit? Is there a clinical benefit? Really tough to do that trial... Even for intact, a very good 6-7 field 3D plan can compare to an IMRT plan, but I never do one first to compare.

Take money out of it. If it paid the same/cost the same, what one would you want? I'd want the IMRT. I don't think it's a slam dunk, but it's what I'd want.

 

[Palex80]

The problem with all IMRT vs. 3D comparisons is, that they often turn into the proton vs. photon arguments.

There are no randomized trials to prove the superiority of either treatment, but most of us know, that there are certain stuff you can only do using IMRT or protons, if you want to give a certain dose to your PTV without risking major damage to the patient.
How we are supposed to do that in a trial is surely a great challenge, since the number are horrifying high and IMRT is so much employed nowadays, many patients will ask: "So you think that IMRT is better than 3D and I could get IMRT without going into the trial. Why should I get randomized and risk getting 3D?"

The problem with IMRT in prostate cancer is that IMRT was brought into practice for pretty much any patients without discrimination and was often used for patients, who didn't need. The 78year old with GS6, PSA 5, T1c tumor does not need 80 Gy IMRT in my opinion, 74 Gy 3D will probably do as well and there isn't much in terms of toxicity he will gain by getting IMRT.

 

[CUBuffsgrad98]

What I tried to explain to on blog...

Essentially, IMRT is theoretically better, and dosimetrically better. If I was a patient, I'd want IMRT. However, I don't think it is worth the extra money. I think the reimbursement should be reflective of effort, and currently the reimbursement is disproportionately higher for a treatment that isn't shown to be better. To me, this is like a surgical technique that had some volume of blood loss that is better than the older technique. It's not going to have any clinical outcome that's better. It's just better because its cleaner. I don't think I should be paid higher for it. But, it's the technique I prefer. If Medicare wants to adjust it and pay us less for it because there isn't any data for it, I'm okay with that. But it doesn't mean I want to stop using it. I have 2 knives in the kitchen. Both make great lamb curry. One takes marginally less time, but not enough less time to watch a sitcom, sometimes in fact the better knife takes longer because I end up talking on the phone while cutting, because it cuts so damn good. But, I love that knife and will keep using it. Even though it's not proven to better, I know it is. I'm willing to pay more for it. I'll eat the cost (I.e. take 3D reimbursement for IMRT treatment) because I know it's better.

Blogger proceeded to show 10 RCTs in general medicine that were theoretically better, but no benefits were borne out in RCTs,

http://theincidentaleconomist.com/wordpress/more-comparative-effectiveness-goodness/

If you care about health policy, this is probably the best one out there, especially if you believe in evidence based medicine. They are fanatics about it, but I think they don't understand oncology all that well. Ezra Klein's wonkblog is good, but it's not all health care.

Any other takes?
S

Interesting points, however, it is more than preference for reimbursement. Remember, these machines cost millions. Reimbursement is for cost (and maintenance) of equipment. Not cheap. If reimbursement is only a "break even", that is only the cost of the equipment and maintenance, then there is no incentive to buy the equipment and really make it happen, just keep doing the same old antiquated things. On an aside, has Cobalt EBRT been proven inferior to photon??