SimulD

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From the NEJM:

Reimbursement Policy and Androgen-Deprivation Therapy for Prostate Cancer

Vahakn B. Shahinian, M.D., Yong-Fang Kuo, Ph.D., and Scott M. Gilbert, M.D.

N Engl J Med 2010; 363:1822-1832November 4, 2010
Background

The Medicare Modernization Act led to moderate reductions in reimbursement for androgen-deprivation therapy (ADT) for prostate cancer, starting in 2004 and followed by substantial changes in 2005. We hypothesized that these reductions would lead to decreases in the use of ADT for indications that were not evidence based.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) Medicare database, we identified 54,925 men who received a diagnosis of incident prostate cancer from 2003 through 2005. We divided these men into groups according to the strength of the indication for ADT use. The use of ADT was deemed to be inappropriate as primary therapy for men with localized cancers of a low-to-moderate grade (for whom a survival benefit of such therapy was improbable), appropriate as adjuvant therapy with radiation therapy for men with locally advanced cancers (for whom a survival benefit was established), and discretionary for men receiving either primary or adjuvant therapy for localized but high-grade tumors. The proportion of men receiving ADT was calculated according to the year of diagnosis for each group. We used modified Poisson regression models to calculate the effect of the year of diagnosis on the use of ADT.

Results

The rate of inappropriate use of ADT declined substantially during the study period, from 38.7% in 2003 to 30.6% in 2004 to 25.7% in 2005 (odds ratio for ADT use in 2005 vs. 2003, 0.72; 95% confidence interval [CI], 0.65 to 0.79). There was no decrease in the appropriate use of adjuvant ADT (odds ratio, 1.01; 95% CI, 0.86 to 1.19). In cases involving discretionary use, there was a significant decline in use in 2005 but not in 2004.

Conclusions

Changes in the Medicare reimbursement policy in 2004 and 2005 were associated with reductions in ADT use, particularly among men for whom the benefits of such therapy were unclear. (Funded by the American Cancer Society.)
 

medgator

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Can't wait til they publish the study of changes in practice patterns in the community for the management of low- and intermediate-risk prostate cancer over the past few years.
 
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clintpark

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I must say it is ironic that, in my practice environment, radiation oncologists administer lupron and place fiducials and urologists give IMRT.
 
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SimulD

SimulD

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I don't care if my house is made of glass. I want to throw stones!!!
-S
 

medgator

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I must say it is ironic that, in my practice environment, radiation oncologists administer lupron and place fiducials and urologists give IMRT.
It was nice in residency to have a urologist place fiducials, but I didn't realize it was harder to get that done in community practice. I always figured they wouldn't mind doing it (if I recall correctly, it's a pretty quick procedure that they can bill for).
 

medgator

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Keep in mind that our field is certainly not above gross-overutilization. Protons for prostate cancer comes to mind.
or just plain ol' IMRT, depending on the situation ;)
 

Palex80

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Question:


Has anyone ever studied what would happen with testosterone levels of prostate cancer patients if you gave something like 40 Gy to the scrotum?

We know from the TIN studies that testosterone levels drop after 14-16 Gy.
Bearing in mind that nowadays patients receiving EBRT for prostate cancer often undergo 3 years of antihormonal treatment, would it be an idea to kill testosterone production of the testis with radiation treatment?
It's a non-invasive procedure (unlike surgical castration), cost-effective (in comparison to LHRH-treatment), with minimal side-effects and you could probably do it while delivering EBRT. One problem is the dynamics of testosterone drop after such a treatment, I presume that the testosterone level won't drop to zero really fast (like it does in the case of LHRH-treatment or surgical castration), but:
a) we don't really know much of the dynamics of testosterone drop after 40 Gy to the testis (or are there any studies in DLBCL-patients?
b) you could always cover this "gap" with LHRH-treatment for six(?) months

I know it sounds a bit crazy, but why not?
 

qwert

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Great paper, thanks for posting!

From the NEJM:

Reimbursement Policy and Androgen-Deprivation Therapy for Prostate Cancer

Vahakn B. Shahinian, M.D., Yong-Fang Kuo, Ph.D., and Scott M. Gilbert, M.D.

N Engl J Med 2010; 363:1822-1832November 4, 2010
Background

The Medicare Modernization Act led to moderate reductions in reimbursement for androgen-deprivation therapy (ADT) for prostate cancer, starting in 2004 and followed by substantial changes in 2005. We hypothesized that these reductions would lead to decreases in the use of ADT for indications that were not evidence based.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) Medicare database, we identified 54,925 men who received a diagnosis of incident prostate cancer from 2003 through 2005. We divided these men into groups according to the strength of the indication for ADT use. The use of ADT was deemed to be inappropriate as primary therapy for men with localized cancers of a low-to-moderate grade (for whom a survival benefit of such therapy was improbable), appropriate as adjuvant therapy with radiation therapy for men with locally advanced cancers (for whom a survival benefit was established), and discretionary for men receiving either primary or adjuvant therapy for localized but high-grade tumors. The proportion of men receiving ADT was calculated according to the year of diagnosis for each group. We used modified Poisson regression models to calculate the effect of the year of diagnosis on the use of ADT.

Results

The rate of inappropriate use of ADT declined substantially during the study period, from 38.7% in 2003 to 30.6% in 2004 to 25.7% in 2005 (odds ratio for ADT use in 2005 vs. 2003, 0.72; 95% confidence interval [CI], 0.65 to 0.79). There was no decrease in the appropriate use of adjuvant ADT (odds ratio, 1.01; 95% CI, 0.86 to 1.19). In cases involving discretionary use, there was a significant decline in use in 2005 but not in 2004.

Conclusions

Changes in the Medicare reimbursement policy in 2004 and 2005 were associated with reductions in ADT use, particularly among men for whom the benefits of such therapy were unclear. (Funded by the American Cancer Society.)
 

hot sauce

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Question:


Has anyone ever studied what would happen with testosterone levels of prostate cancer patients if you gave something like 40 Gy to the scrotum?

We know from the TIN studies that testosterone levels drop after 14-16 Gy.
Bearing in mind that nowadays patients receiving EBRT for prostate cancer often undergo 3 years of antihormonal treatment, would it be an idea to kill testosterone production of the testis with radiation treatment?
It's a non-invasive procedure (unlike surgical castration), cost-effective (in comparison to LHRH-treatment), with minimal side-effects and you could probably do it while delivering EBRT. One problem is the dynamics of testosterone drop after such a treatment, I presume that the testosterone level won't drop to zero really fast (like it does in the case of LHRH-treatment or surgical castration), but:
a) we don't really know much of the dynamics of testosterone drop after 40 Gy to the testis (or are there any studies in DLBCL-patients?
b) you could always cover this "gap" with LHRH-treatment for six(?) months

I know it sounds a bit crazy, but why not?
I think a concern with permanent castration would be the risk of cardiovascular side effects. Obviously we could give testosterone back later but that doesn't seem cost effective.

It also seems like a hard sell to men especially on a protocol.
 

Palex80

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I think a concern with permanent castration would be the risk of cardiovascular side effects. Obviously we could give testosterone back later but that doesn't seem cost effective.

It also seems like a hard sell to men especially on a protocol.
Cardiovascular effects are a main concern for many men, however:

a) lots of the patients we see and who are treated with long-term LHRH-treatment lasting 3 or more years never actually "recover" with normal testosterone levels after LHRH-treatment is ceased
b) very high risk patients are often treated with life-long LHRH-treatment (for example cN+ patients)
 

subatomicdoc

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I don't care if my house is made of glass. I want to throw stones!!!
-S
Urorads lives in the house of glass, so keep throwing. ASTRO has stood up for doing the right thing, and the data is coming to support what we know anecdotally.

Frankly, I think it's an opportunity to work more closely with PCPs. Advocate for shared decision making that includes PCPs in deciding to treat. Let surgeons talk about surgery, radiation oncologists talk about radiation, then PCPs review whether any treatment is necessary based upon comorbidity and less bias.