Reimbursement policy and androgen-deprivation therapy for prostate cancer

Urologist practice divestment from radiation vault ownership and treatment patterns for prostate cancer

BACKGROUND

Urologists practicing in single-specialty groups with ownership in radiation vaults are more likely to treat men with prostate cancer. The effect of divestment of vault ownership on treatment patterns is unclear.

METHODS

A 20% sample of national Medicare claims was used to perform a retrospective cohort study of men with prostate cancer diagnosed between 2010 and 2019. Urology practices were categorized by radiation vault ownership as nonowners, continuous owners, and divested owners. The primary outcome was use of local treatment, and the secondary outcome was use of intensity-modulated radiation therapy (IMRT). A difference-in-differences framework was used to measure the effect of divestment on outcomes compared to continuous owners. Subgroup analyses assessed outcomes by noncancer mortality risk (high [>50%] vs. low [≤50%]).

RESULTS

Among 72 urology practices that owned radiation vaults, six divested during the study. Divestment led to a decrease in treatment compared with those managed at continuously owning practices (difference-in-differences estimate, -13%; p = .03). The use of IMRT decreased, but this was not statistically significant (difference-in-differences estimate, -10%; p = .13). In men with a high noncancer mortality risk, treatment (difference-in-differences estimate, -28%; p < .001) and use of IMRT (difference-in-differences estimate, -27%; p < .001) decreased after divestment.

CONCLUSIONS

Urology group divestment from radiation vault ownership led to a decrease in prostate cancer treatment. This decrease was most pronounced in men who had a high noncancer mortality risk. This has important implications for health care reform by suggesting that payment programs that encourage constraints on utilization, when appropriate, may be effective in reducing overtreatment.

Androgen Deprivation Therapy/Androgen Receptor Signaling Inhibitor Treatments for Prostate Cancer: Pathophysiology and Review of Effects on Cardiovascular Disease

Androgen deprivation therapy is the cornerstone of systemic management for prostate cancer but is associated with multiple adverse effects that must be considered during treatment. These effects occur because of the profound hypogonadism that is induced from lack of testosterone or due to the medications used in the treatment or in combination with androgen receptor signaling inhibitors. This article critically reviews the associations between androgen deprivation therapy, androgen receptor signaling inhibitors, and cardiovascular complications such as prolonged QT interval, atrial fibrillation, heart failure, atherosclerosis, coronary heart disease, venous thromboembolism, and peripheral arterial occlusive disease. These unfavorable outcomes reinforce the need for regular cardiovascular screening of patients undergoing androgen deprivation for the management of prostate cancer.

Follicle-Stimulating Hormone Exacerbates Cardiovascular Disease in the Presence of Low or Castrate Testosterone Levels

Low testosterone (T), common in aging men, associates with cardiovascular disease. We investigated whether follicle-stimulating hormone (FSH), which is affected by T, modulates the cardiovascular effects associated with low T or castration. FSHβ-/-:low-density lipoprotein receptor (LDLR)-/- mice, untreated or castrated (orchiectomy, gonadotropin-releasing hormone agonist or antagonist), demonstrated significantly less atherogenesis compared with similarly treated LDLR-/- mice, but not following FSH delivery. Smaller plaque burden in LDLR-/- mice receiving gonadotropin-releasing hormone antagonists vs agonists were nullified in FSHβ-/-:LDLR-/- mice. Atherosclerotic and necrotic plaque size and macrophage infiltration correlated with serum FSH/T. In patients with prostate cancer, FSH/T following androgen-deprivation therapy initiation predicted cardiovascular events. FSH facilitates cardiovascular disease when T is low or eliminated.

Value-based payment models and management of newly diagnosed prostate cancer

OBJECTIVE

To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer.

METHODS

Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis.

RESULTS

Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]).

CONCLUSIONS

How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.

Physician responses to Medicare reimbursement rates

This paper investigates how office-based physicians respond to Medicare reimbursement changes. Using variation from an Affordable Care Act policy that increased reimbursements for office-based care in four states, we use a triple difference analysis, comparing physicians with higher and lower reimbursement changes in treated states to similar physicians in untreated states. We find two mechanisms through which physicians respond. First, the reimbursement change affected integration-physicians with larger increases in office-based reimbursement were less likely to vertically integrate with hospitals and more likely to continue providing office-based care than physicians with smaller reimbursement increases. Second, we find some evidence that physicians who continued practicing in an office setting increased the volume of services provided.

Health care delivery system contributions to management of newly diagnosed prostate cancer

BACKGROUND

Despite clinical guidelines advocating for use of conservative management in specific clinical scenarios for men with prostate cancer, there continues to be tremendous variation in its uptake. This variation may be amplified among men with competing health risks, for whom treatment decisions are not straightforward. The degree to which characteristics of the health care delivery system explain this variation remains unclear.

METHODS

Using national Medicare data, men with newly diagnosed prostate cancer between 2014 and 2019 were identified. Hierarchical logistic regression models were used to assess the association between use of treatment and health care delivery system determinants operating at the practice level, which included measures of financial incentives (i.e., radiation vault ownership), practice organization (i.e., single specialty vs. multispecialty groups), and the health care market (i.e., competition). Variance was partitioned to estimate the relative influence of patient and practice characteristics on the variation in use of treatment within strata of noncancer mortality risk groups.

RESULTS

Among 62,507 men with newly diagnosed prostate cancer, the largest variation in the use of treatment between practices was observed for men with high and very high-risk of noncancer mortality (range of practice-level rates of treatment for high: 57%-71% and very high: 41%-61%). Addition of health care delivery system determinants measured at the practice level explained 13% and 15% of the variation in use of treatment among men with low and intermediate risk of noncancer mortality in 10 years, respectively. Conversely, these characteristics explained a larger share of the variation in use of treatment among men with high and very high-risk of noncancer mortality (26% and 40%, respectively).

CONCLUSIONS

Variation among urology practices in use of treatment was highest for men with high and very high-risk noncancer mortality. Practice characteristics explained a large share of this variation.

The 17-Gene Genomic Prostate Score Assay Is Prognostic for Biochemical Failure in Men With Localized Prostate Cancer After Radiation Therapy at a Community Cancer Center

Purpose

The objective of this study was to assess the association between the Oncotype DX Genomic Prostate Score (GPS) assay and long-term outcomes in men with localized prostate cancer (PCa) after radiation therapy (RT). We hypothesized that the GPS assay is prognostic for biochemical failure (BCF), along with distant metastasis (DM) and PCa-specific mortality in patients with PCa receiving RT.

Methods and Materials

We retrospectively studied men with localized PCa treated with definitive RT at Georgia Urology from 2010 to 2016. The primary objective was to assess the association between GPS results and time to BCF per the Phoenix criteria; we also assessed time to DM and PCa-specific mortality. We used Cox proportional hazards regression models for all analyses, with clinicopathologic covariates determined a priori for multivariable modeling.

Results

A total of 450 patients (median age, 65 years; 35% Black) met eligibility criteria. There was a strong univariable association between GPS result and time to BCF (hazard ratio [HR] per 20-unit increase = 3.08; 95% confidence interval [CI], 2.11-4.46; P < .001), which persisted after adjusting for clinicopathologic characteristics in multivariable analyses. We also observed this association for time to DM (HR = 5.19; 95% CI, 3.06-8.77; P < .001) and PCa-specific mortality (HR = 13.07; 95% CI, 4.42-49.39; P < .001). Race was not a predictor of time to BCF or DM, and the GPS assay was strongly prognostic for all endpoints in Black and White patients.

Conclusions

In a community-based cohort, the GPS assay was strongly prognostic for time to BCF as well as long-term outcomes in men treated with RT for localized PCa.

Practice Competition and Treatment of Newly Diagnosed Prostate Cancer

OBJECTIVE

To examine the effect of urology practice market competition on use of treatment in men with newly diagnosed prostate cancer.

METHODS

We performed a retrospective national cohort study of 48,067 Medicare beneficiaries with newly diagnosed prostate cancer between 2014 and 2018. The primary exposure was urology practice-level market competition. Markets were established by the flow of patients to a practice using a variable radius approach. Practice level competition was measured annually using the Herfindahl-Hirschman Index. The primary outcome was use of treatment for prostate cancer (ie, surgery, radiation, or cryotherapy) stratified by 10-year risk of noncancer mortality.

RESULTS

Between 2014 and 2018, there was a decrease in the total percent of urologists practicing in small single-specialty groups (49%-41%) with an increase in multispecialty practices (38%-47%). After adjusting for demographic and clinical characteristics, a lower percentage of men underwent treatment in practices with low competition relative to those managed in practices with high competition (70% vs 67.0%, P < .001). Among men with the highest risk of noncancer mortality, those managed in practices in the least competitive markets were less likely to receive treatment relative to men managed by practices in the most competitive markets (48% vs 60%, P-value<.001).

CONCLUSION

Reduction in competition between urology practices is not associated with greater use of treatment in men with newly diagnosed prostate cancer, particularly in those with a high risk of noncancer mortality.

Androgen-deprivation therapy with leuprolide increases abdominal adiposity without causing cardiac dysfunction in middle-aged male mice: effect of sildenafil

Androgen-deprivation therapy (ADT) is the primary systemic therapy for treating advanced or metastatic prostate cancer (PCa), which has improved survival outcomes in patients with PCa. However, ADT may develop metabolic and cardiovascular adverse events that impact the quality of life and lifespan in PCa survivors. The present study was designed to establish a murine model of ADT with a gonadotropin-releasing hormone (GnRH) agonist leuprolide and to investigate its effects on metabolism and cardiac function. We also examined the potential cardioprotective role of sildenafil (inhibitor of phosphodiesterase 5) under chronic ADT. Middle-aged male C57BL/6J mice received a 12-wk subcutaneous infusion via osmotic minipumps containing either saline or 18 mg/4 wk leuprolide with or without 1.3 mg/4 wk sildenafil cotreatment. Compared with saline controls, leuprolide treatment significantly reduced prostate weight and serum testosterone levels, confirming chemical castration in these mice. The ADT-induced chemical castration was not affected by sildenafil. Leuprolide significantly increased the weight of abdominal fat after 12-wk treatment without a change in total body weight, and sildenafil did not block the proadipogenic effect of leuprolide. No signs of left ventricular systolic and diastolic dysfunction were observed throughout the leuprolide treatment period. Interestingly, leuprolide treatment significantly elevated serum levels of cardiac troponin I (cTn-I), a biomarker of cardiac injury, and sildenafil did not abolish this effect. We conclude that long-term ADT with leuprolide increases abdominal adiposity and cardiac injury biomarker without cardiac contractile dysfunction. Sildenafil did not prevent ADT-associated adverse changes.

Adverse cardiovascular effect following gonadotropin-releasing hormone antagonist versus GnRH agonist for prostate cancer treatment: A systematic review and meta-analysis

Background

Androgen deprivation therapy is the mainstay of medical treatment for prostate cancer (Pca); however, it is associated with an increased risk of adverse cardiovascular (CV) events and death. To date, CV death has been the leading noncancer cause of death in Pca patients. Both GnRH antagonists (an emerging class of drugs) and GnRH agonists (most frequently prescribed) are efficacious against Pca. However, the adverse effects, especially the adverse CV effect between them remain unclear.

Methods

Through a literature search using MEDLINE, EMBASE and the Cochrane Library, all available studies comparing the safety of CV risk between GnRH antagonists and GnRH agonists in Pca patients were extracted. Comparisons of outcomes of interest between these two classes of drugs were calculated using the risk ratio (RR). Subgroup analyses were performed depending on the study design and preexisting CV disease at baseline.

Results

Nine randomized controlled clinical trials (RCTs) and five real-world observational studies comprising 62160 Pca patients were included in our meta-analysis. Patients receiving GnRH antagonists experienced fewer CV events (RR: 0.66, 95% CI:0.53-0.82, P<0.001), CV death (RR:0.4, 95% CI: 0.24-0.67, P<0.001) and myocardial infarctions (RR: 0.71, 95% CI: 0.52-0.96, P=0.03). No difference was found in the incidence of stroke and heart failure. Moreover, GnRH antagonists were associated with fewer CV events in patients with preexisting CV disease but not in those without preexisting CV disease in the RCT series.

Conclusion

GnRH antagonists appear to offer favorable safety in terms of adverse CV events and CV death compared with GnRH agonists among men diagnosed with Pca, especially those who had established CV disease at baseline.

Systematic review registration

https://inplasy.com/inplasy-2023-2-0009/, identifier INPLASY202320009.

Trends in Urethral Suspension With Robotic Prostatectomy Procedures Following Medicare Payment Policy Changes

IMPORTANCE

In 2016, the Centers for Medicare and Medicaid Services cut payments for robotic prostatectomy performed for Medicare beneficiaries. Although regulations mandate that billing for urethral suspension is only acceptable for preexisting urinary incontinence, reductions in reimbursement may incentivize billing for the use of this procedure in other scenarios.

OBJECTIVE

To assess trends and geographic variations in payments for urethral suspension with robotic prostatectomy in the context of Medicare payment policy.

DESIGN, SETTING, AND PARTICIPANTS

This US population-based retrospective cohort study analyzed data from the IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental Database for men with employer-based insurance (primary commercial or Medicare supplemental coverage) who underwent robotic prostatectomy (Current Procedural Terminology [CPT] code 55866) between 2009 and 2019.

EXPOSURES

Time period and metropolitan statistical area of patient residence.

MAIN OUTCOMES AND MEASURES

Payment for urethral suspension (CPT code 51990) with robotic prostatectomy.

RESULTS

We identified 87 774 men with prostate cancer treated with robotic prostatectomy; 3352 (3.8%) had undergone urethral suspension. The mean (SD) patient age was 59.7 (6.5) years; 16 870 patients (19.2%) had Medicare supplemental coverage. From 2015 to 2016, median payments for robotic prostatectomy changed by -$358 (-17.0%) for Medicare beneficiaries vs -$9 (0%) for commercially insured patients. With urethral suspension vs without, median (IQR) episode payments for robotic prostatectomy were higher for commercially insured men ($3678 [$3090-$4503] vs $3322 [$2601-$4306]) and Medicare beneficiaries ($2927 [$2450-$3909] vs $2379 [$2014-$3512]). Compared with men treated between 2013 and 2015, those treated between 2016 and 2017 were twice as likely to undergo urethral suspension (8.5% vs 4.1%; odds ratio, 2.17 [95% CI, 1.96-2.38]). The proportion of patients who underwent urethral suspension was stable for 2018 to 2019 and 2016 to 2017 (8.5% vs 9.0%; odds ratio, 1.06 [95% CI, 0.96-1.18]). From 2015 to 2019, the proportion of patients who underwent urethral suspension was highest in Charleston, South Carolina (92.0%), Knoxville, Tennessee (66.0%), and Columbia, South Carolina (58.0%). These regions neighbored high-volume areas without patients who underwent prostatectomy with urethral suspension (eg, 146 patients in Greenville, South Carolina, and 173 in Nashville, Tennessee).

CONCLUSIONS AND RELEVANCE

In this study, urethral suspension was associated with increased costs for patients with both commercial insurance and Medicare. Patients treated between 2016 and 2017 were more likely than those treated between 2013 and 2015 to undergo this procedure. Geographic variation in use exceeded what was expected for the preexisting condition for which billing is permitted for Medicare beneficiaries. Policy statements from professional societies highlighting appropriate billing for urethral suspension may have tempered, but not reversed, the broad adoption of this procedure.

Implicaciones de la pandemia en la radioterapia para el cáncer de mama. Omisión de la radioterapia

La pandemia actual por el nuevo coronavirus (SARS-CoV-2) exige que los sistemas de salud rápidamente adopten medidas encaminadas a mitigar la crisis, lo que implica redistribuir los recursos económicos, sociales y la fuerza laboral, para que aquellos sectores de la población más afectados puedan ser atendidos de forma óptima y oportuna. En los pacientes con carcinoma mamario in situ e invasivo de bajo riesgo, la radioterapia postoperatoria no ofrece ningún beneficio en supervivencia global, lo que hace atractiva la idea de omitir este recurso oncológico. En este artículo, se realizó una revisión de la literatura sobre los criterios para omitir la radioterapia adyuvante en los pacientes con neoplasias mamarias de bajo riesgo. Adicionalmente, se resumen las recomendaciones emitidas por algunas sociedades científicas internacionales durante la contingencia actual, y se analizan determinadas razones por las cuales los médicos se rehúsan a cambiar conductas clínicas que ofrecen ventajas limitadas, muchas veces contrarrestadas por los riesgos y los efectos adversos asociados.

Learning from the "tail end" of de-implementation: the case of chemical castration for localized prostate cancer

BACKGROUND

Men with prostate cancer are often treated with the suppression of testosterone through long-acting injectable drugs termed chemical castration or androgen deprivation therapy (ADT). In most cases, ADT is not an appropriate treatment for localized prostate cancer, indicating low-value care. Guided by the Theoretical Domains Framework (TDF) and the Behavior Change Wheel's Capability, Opportunity, Motivation Model (COM-B), we conducted a qualitative study to identify behavioral determinants of low-value ADT use to manage localized prostate cancer, and theory-based opportunities for de-implementation strategy development.

METHODS

We used national cancer registry and administrative data from 2016 to 2017 to examine the variation in low-value ADT use across Veterans Health Administration facilities. Using purposive sampling, we selected high- and low-performing sites to conduct 20 urology provider interviews regarding low-value ADT. We coded transcripts into TDF domains and mapped content to the COM-B model to generate a conceptual framework for addressing low-value ADT practices.

RESULTS

Our interview findings reflected provider perspectives on prescribing ADT as low-value localized prostate cancer treatment, including barriers and facilitators to de-implementing low-value ADT. We characterized providers as belonging in 1 of 3 categories with respect to low-value ADT use: 1) never prescribe 2); willing, under some circumstances, to prescribe: and 3) prescribe as an acceptable treatment option. Provider capability to prescribe low-value ADT depended on their knowledge of localized prostate cancer treatment options (knowledge) coupled with interpersonal skills to engage patients in educational discussion (skills). Provider opportunity to prescribe low-value ADT centered on the environmental resources to inform ADT decisions (e.g., multi-disciplinary review), perceived guideline availability, and social roles and influences regarding ADT practices, such as prior training. Provider motivation involved goals of ADT use, including patient preferences, beliefs in capabilities/professional confidence, and beliefs about the consequences of prescribing or not prescribing ADT.

CONCLUSIONS

Use of the TDF domains and the COM-B model enabled us to conceptualize provider behavior with respect to low-value ADT use and clarify possible areas for intervention to effect de-implementation of low-value ADT prescribing in localized prostate cancer.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03579680.

Trends and variations in utilization and costs of radiotherapy for prostate cancer: A SEER medicare analysis from 2007 through 2016

OBJECTIVE

To assess recent changes and disparities in utilization and costs of radiotherapy in Medicare beneficiaries with prostate cancer.

METHODS

Surveillance, Epidemiology and End Results (SEER) -Medicare linked data from 2006-2016 were used to identify continuously enrolled Medicare beneficiaries with a first-time diagnosis of prostate cancer who, within 12 months of diagnosis, underwent at least one radiotherapy related service. Trends in the utilization of different radiotherapy techniques over time, yearly changes in per-patient costs of radiotherapy, and effect of socio-demographic and clinical characteristics on total cost were measured. Per patient annual costs, annual incidence of prostate cancer, and utilization of radiotherapy were used to estimate total costs of radiotherapy to the Medicare program.

RESULTS

For Medicare beneficiaries with a first-time diagnosis of prostate cancer, the utilization of intensity modulated radiation therapy (IMRT), proton therapy, and stereotactic body radiation therapy (SBRT) increased 23.62%, 0.74% and 1.61% respectively (p <0.0001) while brachytherapy decreased 17.04% (p <0.0001). Cost per beneficiary decreased $340.24 (95% CI: $136.05 - $544.43) annually (p = 0.0065). Age, registry region, and Gleason score were all associated with expenditures. The total cost to the Medicare program was estimated at US $1.16 billion in the year 2016.

DISCUSSION

In Medicare beneficiaries with prostate cancer treated with radiotherapy, IMRT is the primary mode of treatment. Utilization of brachytherapy decreased significantly despite the efficacy and cost-effectiveness. Although per patient costs have decreased, the share of patient responsibility remained unaltered across years. The current costs to Medicare of radiotherapy for newly diagnosed prostate cancer patients is substantial.

Medicare fee reductions and the overuse of intensity-modulated radiotherapy

OBJECTIVE

To estimate the impact of a large Medicare fee reduction for intensity-modulated radiation therapy (IMRT) on its use in prostate and breast cancer patients.

DATA SOURCES/STUDY SETTING

SEER-Medicare.

STUDY DESIGN

We compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics) and patients treated in other types of practices.

DATA COLLECTION/EXTRACTION METHODS

We identified breast and prostate cancer patients receiving IMRT using outpatient and physician office claims. We classified urology practices based on whether they billed for IMRT and radiotherapy clinics based on whether they were reimbursed under the Physician Fee Schedule.

PRINCIPAL FINDINGS

Between 2006 and 2015 the payment for IMRT delivered in freestanding clinics and physician offices declined by $367 (-54.7%). However, the use of IMRT increased in physician practices subject to payment cuts, both in absolute terms and relative to use in practices unaffected by the payment cut. Use of IMRT in prostate cancer patients treated at urology practices that own IMRT equipment increased by 9.1 (95% CI: 2.0-16.2) percentage points between 2005 and 2016 relative to use in patients treated at other urology practices. Use of IMRT in breast cancer patients treated at freestanding radiotherapy centers increased by 7.5 (95% CI: -5.1 to 20.1) percentage points relative to use in patients treated at hospital-based centers.

CONCLUSIONS

A steep decline in IMRT fees did not decrease IMRT use over the period from 2006 to 2015, though use has declined since 2010.

Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists

BACKGROUND

Clinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists' recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting.

METHODS

We conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention.

RESULTS

Community and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient's ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation.

CONCLUSIONS

Despite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.

Association of Utilization Management Policy With Uptake of Hypofractionated Radiotherapy Among Patients With Early-Stage Breast Cancer

Importance

Breast cancer accounts for the largest portion of cancer-related spending in the United States. Although hypofractionated radiotherapy after breast-conserving surgery is a cost-effective and convenient treatment strategy for patients with early-stage breast cancer, less than 40% of eligible women received hypofractionated radiotherapy in 2013.

Objective

To assess the association of a large commercial payer's utilization management policy with the use of hypofractionated radiotherapy among women with early-stage breast cancer and its associated cost.

Design, Setting, and Participants

A retrospective, adjusted difference-in-differences economic analysis was conducted using administrative claims data from January 1, 2012, to June 1, 2018, of women 18 years or older with early-stage breast cancer who were eligible for hypofractionated radiotherapy according to 2011 guidelines from the American Society for Radiation Oncology and were continuously enrolled in 14 geographically diverse commercial health plans covering 6.9% of US adult women. Women who received mastectomy, brachytherapy, or less than 11 or more than 40 external beam fractions of radiotherapy were excluded. A utilization management policy was used to encourage the use of hypofractionated radiotherapy among women in fully insured and Medicare Advantage (fully insured) plans. Under the new policy, claims for extended-course radiotherapy were not reimbursed for fully insured women who were eligible for hypofractionated radiotherapy. This policy did not apply to women in self-insured or Medicare supplemental insurance (self-insured) plans, allowing these groups to serve as a comparison group.

Main Outcomes and Measures

The primary outcome was use of hypofractionated radiotherapy, and the secondary outcome was the cost of this type of radiotherapy.

Results

Of 10 540 eligible women, 3619 (34.3%) were in fully insured plans and thus subject to the policy. There were no meaningful differences between the fully insured and self-insured groups in mean (SD) age at the start of radiotherapy (63.8 [8.6] vs 65.0 [8.9] years), mean (SD) Charlson Comorbidity Index score (3.0 [1.5] vs 3.2 [1.6]), or practice setting (outpatient hospital setting, 2982 of 3619 [82.4%] vs 5600 of 6921 [80.9%]). The policy was associated with an increase in use of hypofractionated radiotherapy among fully insured patients subject to the policy (adjusted percentage point difference-in-difference, 4.2%; 95% CI, 0.0%-8.4%; P = .05) and a nonsignificant decrease in radiotherapy-associated expenditures (-$2275 relative to self-insured patients; P = .09). Spillover analyses revealed a significantly higher uptake of hypofractionated radiotherapy among self-insured patients who were indirectly exposed to the policy (adjusted percentage point difference-in-difference, 8.5%; 95% CI, 3.6%-13.5%; P < .001) compared with those who were not exposed.

Conclusions and Relevance

This study suggests that a payer's utilization management policy was associated with direct and spillover increases in the use of hypofractionated radiotherapy, even after accounting for a long-term secular trend in the uptake of hypofractionated radiotherapy in the control groups. Utilization management may promote evidence-based cancer care.

THE CARDIOVASCULAR EFFECTS OF GNRH ANTAGONISTS IN MEN WITH PROSTATE CANCER

AIMS

The aim of this study was to determine whether gonadotropin-releasing hormone (GnRH) antagonists (an emerging class of drugs to suppress testosterone synthesis in the treatment of prostate cancer) cause less adverse cardiovascular events than the more commonly use GnRH agonists.

METHODS AND RESULTS

We conducted a systematic review to identify all randomised, controlled trials in which a GnRH antagonist was compared with a GnRH agonist in men with prostate cancer. We identified ten eligible studies including two different GnRH antagonists, degarelix (n = 1681) and relugolix (n = 734), which were compared with the GnRH agonists, leuprolide (n = 714) and goserelin (n = 600). The pooled risk ratios (95% confidence intervals) among GnRH antagonist recipients for adverse cardiovascular events, cardiovascular death and all-cause mortality were 0.57 (0.39-0.81); 0.49 (0.25-0.96); and 0.48 (0.28-0.83) respectively. Important limitations of the included trials were their short duration of follow-up, unblinded study design and (in most of the studies) the identification of adverse cardiovascular events through safety reporting mechanisms rather than as a pre-specified outcome. There was no evidence of heterogeneity of findings among the studies.

CONCLUSIONS

There is consistent but methodologically limited data to suggest that GnRH antagonists - a relatively new class of androgen deprivation therapy for prostate cancer - cause significantly less cardiovascular adverse effects than the more frequently used GnRH agonists.

Cardiovascular Toxicities of Androgen Deprivation Therapy

OPINION STATEMENT

Prostate cancer is the second leading cause of cancer death in men, and cardiovascular disease is the number one cause of death in patients with prostate cancer. Androgen deprivation therapy, the cornerstone of prostate cancer treatment, has been associated with adverse cardiovascular events. Emerging data supports decreased cardiovascular risk of gonadotropin releasing hormone (GnRH) antagonists compared to agonists. Ongoing clinical trials are assessing the relative safety of different modalities of androgen deprivation therapy. Racial disparities in cardiovascular outcomes in prostate cancer patients are starting to be explored. An intriguing inquiry connects androgen deprivation therapy with reduced risk of COVID-19 infection susceptibility and severity. Recognition of the cardiotoxicity of androgen deprivation therapy and aggressive risk factor modification are crucial for optimal patient care.

Documenting Horizontal Integration Among Urologists Who Treat Prostate Cancer

Relatively little is known about the extent and effects of horizontal mergers among physician specialists. We developed and implemented a methodology to document changes in physician practice structure resulting from horizontal integration among urology groups. We merged cancer registry records from four large states with Medicare Part B claims to identify all urologists who treated men with prostate cancer. We added information from SK & A surveys and extensive internet searches to assign a practice structure to each urologist-year (2005-2014). Horizontal integration among small urology groups led to a sharp increase in the proportion of urologists who belong to large urology practices with ownership in intensity modulated radiation therapy and/or anatomical pathology services. By 2014, more than half of New Jersey urologists and about 43% of urologists in Florida and Texas were members of such large practices, whereas small percentages (7%-16%) were employed by a health system. In contrast, more than 27% of California urologists were employed but only 17.5% had ownership in intensity modulated radiation therapy and/or pathology services. Importantly, we found our indicators of market share of urologists associated with each practice structure type were highly concordant with indicators of market share based on number of prostate cancer episodes treated by each practice structure type.

The relationship between androgen deprivation therapy and depression symptoms in patients with prostate cancer

AIM

In this study, we administered a questionnaire to consecutive prostate cancer patients who received androgen deprivation therapy (ADT) for understanding the prevalence of depression symptoms.

MATERIALS AND METHODS

We retrospectively identified patients with prostate adenocarcinoma who received ADT between January 2015 and February 2018 at Mackay Memorial Hospital. The patients were then asked to complete the Chinese version of the Patient Health Questionnaire-9 (PHQ-9) during an interview. The patients were divided into two groups according to PHQ-9 score: those with depression symptoms (PHQ-9 ≥ 6, depression group), and those without depression symptoms (PHQ-9 < 6, non-depression group). Two groups were compared using t-tests and correlation coefficients, as appropriate. Statistical significance was set at p < .05.

RESULTS

There were no significant correlations between PHQ-9 scores and any of the parameters in the patients overall. In subgroup analysis, a positive correlation was found between the duration of ADT and PHQ-9 score in the patients with depression symptoms (p = .03). In addition, univariate analysis showed a positive association between the duration of ADT and PHQ-9 score, and a longer duration of ADT was further independently associated with increased PHQ-9 score in multivariate analysis in the patients with depression symptoms.

CONCLUSION

This study demonstrated that in patients with prostate cancer and depression symptoms, the severity of the depression symptoms was positively correlated with the duration of ADT. In contrast, this association was not found in patients without depression symptoms.

Surgical versus Medical Castration for Metastatic Prostate Cancer: Use and Overall Survival in a National Cohort

PURPOSE

Surgical castration for metastatic prostate cancer is used less frequently than medical castration yet costs less, requires less followup and may be associated with fewer adverse effects. We evaluated temporal trends and factors associated with the use of surgical castration.

MATERIALS AND METHODS

This retrospective cohort study sampled 24,805 men with newly diagnosed (de novo) metastatic prostate cancer from a national cancer registry in the United States (2004 to 2016). Multivariable logistic regression assessed the association between sociodemographic factors and surgery. Multivariable Cox regression evaluated the association between castration type and overall survival.

RESULTS

Overall 5.4% of men underwent surgical castration. This figure decreased from 8.5% in 2004 to 3.5% in 2016 (per year later OR 0.89, 95% CI 0.87-0.91, p <0.001). Compared to Medicare, private insurance was associated with less surgery (OR 0.73, 95% CI 0.61-0.87, p <0.001) while Medicaid or no insurance was associated with more surgery (OR 1.68, 95% CI 1.34-2.11, p <0.001 and OR 2.12, 95% CI 1.58-2.85, p <0.001, respectively). Regional median income greater than $63,000 was associated with less surgery (vs income less than $38,000 OR 0.61, 95% CI 0.43-0.85, p=0.004). After a median followup of 30 months castration type was not associated with differences in survival (surgical vs medical HR 1.02, 95% CI 0.95-1.09, p=0.6).

CONCLUSIONS

In a contemporary, real-world cohort surgical castration use is low and decreasing despite its potential advantages and similar survival rate compared to medical castration. Men with potentially limited health care access undergo more surgery, perhaps reflecting a provider bias toward the perceived benefit of permanent castration.

Promotional Payments Made to Urologists by the Pharmaceutical Industry and Prescribing Patterns for Targeted Therapies

OBJECTIVE

To measure the association between market-level promotional payments to urologists by the manufacturers of abiraterone and enzalutamide and national prescribing patterns.

METHODS

A 20% national sample of the 2015 Part D event file was used to identify patients filling their first prescription for abiraterone and enzalutamide and their prescribing physicians. The 2015 Open Payments data were used to characterize promotional payments made to physicians at the market level. Generalized linear models were then used to measure the relationship between market-level payments to urologists and the physician specialty prescribing abiraterone or enzalutamide for the first time RESULTS: In 2015, 2318 men filled a prescription for abiraterone or enzalutamide by a urologist or medical oncologist. Increasing market-level promotional payments to urologists for abiraterone or enzalutamide was strongly associated with a urologist prescribing either drug-24.3% versus 5.8% of those residing in the markets with highest and lowest level of promotional payments to urologists, respectively (P <.01). Neither the number of urologists residing in a market nor other promotional payment measures (ie, to medical oncologists for these drugs, or to all physicians for all other drugs) were associated with a urologist prescribing either drug.

CONCLUSION

Promotional payments to urologists at the market level are strongly associated with the specialty of the physician prescribing abiraterone or enzalutamide for the first time. Future work should elucidate the effects of the shift in prescribing patterns on quality of care and financial hardship for men with advanced prostate cancer.

Protective effect of pharmacological castration on metabolic perturbations and cardiovascular disease in the hyperglycemic male ApoE-/-:Ins2+/Akita mouse model

BACKGROUND

Unlike in other mouse models of atherogenesis, it has recently been suggested that orchiectomy plays a role in accelerating atherosclerosis and inhibiting the progression of cardiovascular disease in the ApoE^-/-:Ins2^+/Akita mouse model of hyperglycemia. Androgen-deprivation therapy (ADT) is a common treatment for prostate cancer, a population with high prevalence of cardiovascular disease and its risk factors. Our objectives were to test and further characterize the effects of pharmacological castration which is currently the acceptable modality to deliver ADT in the clinic.

METHODS

Male ApoE^-/-:Ins2^+/Akita mice received one of three modes of ADT (gonadotropin-releasing hormone (GnRH)-antagonist (degarelix), GnRH-agonist (leuprolide), or bilateral orchiectomy) and were compared to corresponding untreated control mice (n = 9-13/group). Mice were followed for 5 months. Body weight, fasting blood glucose, glucose tolerance, serum C-peptide, leptin, and testosterone levels along with atherosclerotic aortic plaque size and characteristics were determined. In a separate experiment, the survival of mice, untreated and on ADT, was determined.

RESULTS

Castration was achieved for all three modes of ADT. However, degarelix-treated mice gained significantly less weight, had lower serum leptin levels and systolic blood pressure compared to orchiectomy and leuprolide-treated mice. ADT improved dysglycemia and atherosclerotic burden. GnRH-antagonist significantly improved survival compared to GnRH-agonist but not compared to orchiectomy.

CONCLUSIONS

Further characterization of the ApoE^-/-:Ins2^+/Akita mouse model confirms that pharmacological ADT ameliorated metabolic syndrome and cardiovascular complications. Improved dysglycemia and atherosclerosis associated with increased survival which was longest after degarelix followed by orchiectomy.

Cardiovascular risks and toxicity - The Achilles heel of androgen deprivation therapy in prostate cancer patients

Androgen deprivation therapy (ADT) is the primary systemic therapy for treating locally advanced or metastatic prostate cancer (PCa). Despite its positive effect on PCa patient survival, ADT causes various adverse effects, including increased cardiovascular risk factors and cardiotoxicity. Lifespans extension, early use of ADT, and second-line treatment with next-generation androgen receptor pathway inhibitors would further extend the duration of ADT and possibly increase the risk of ADT-induced cardiotoxicity. Meanwhile, information on the molecular mechanisms underlying ADT-induced cardiotoxicity and measures to prevent it is limited, mainly due to the lack of specifically designed preclinical studies and clinical trials. This review article compiles up-to-date evidence obtained from observational studies and clinical trials, in order to gain new insights for deciphering the association between ADT use and cardiotoxicity. In addition, potential cardioprotective strategies involving GnRH receptors and second messenger cGMP are discussed.

The effects of the Medicare NCS reimbursement policy: Utilization, payments, and patient access

OBJECTIVE

To determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by performing a retrospective analysis of Medicare data (2012-2016 fee-for-service data from the CMS Physician and Other Supplier Public Use File).

METHODS

Individual billable services were identified by Healthcare Common Procedure Coding System Current Procedural Terminology and G codes. Medicare use and payments were stratified by specialty and type of service (electrodiagnostic tests, including NCS and EMG, and other neurologic procedures). We also assessed access to Medicare physicians using the annual number of unique beneficiaries receiving initial Evaluation and Management (E/M) services.

RESULTS

We identified 676,113 Medicare providers included in all analysis years from 2012 to 2016 (10,599 neurologists, 5,881 physiatrists, and 659,633 other specialties). Comparing 2016 to 2012 showed that 21.1% fewer neurologists, 28.6% fewer physiatrists, and 69.3% fewer other specialists performed NCS and 3.8% fewer neurologists, 21.7% fewer physiatrists, and 5.6% fewer other specialists performed EMG. For NCS providers in 2012, the mean number of unique Medicare beneficiaries increased for neurologists (1.2%) and physiatrists (4.8%) but decreased for other specialists (-6.5%) by 2016. After the NCS cut, the number of providers performing autonomic and evoked potential testing increased substantially.

CONCLUSIONS

The Medicare NCS reimbursement policy resulted in a larger decrease in NCS providers than in EMG providers. Despite fewer neurologists and physiatrists performing NCS, Medicare access to these physicians for E/M services was not affected. Increased autonomic and evoked potential testing may be an unintended consequence of NCS reimbursement change.

Androgen deprivation therapy and the risk of iron-deficiency anaemia among patients with prostate cancer: a population-based cohort study

OBJECTIVES

The administration of androgen deprivation therapy (ADT) to patients with metastatic prostate cancer might be associated with some adverse effects such as anaemia; however, few studies have been performed in East Asian populations. This study aimed to investigate the association between ADT and iron-deficiency anaemia (IDA) among patients with prostate cancer in a population-based nationwide cohort.

DESIGN

Cohort study.

SETTING

Taiwan.

PARTICIPANTS

Data for the cohort study were retrieved from the Taiwan National Health Insurance Research Database. Propensity score matching was used to select 7262 patients with prostate cancer who received ADT as the study group and 3631 patients who did not receive ADT as the control group.

PRIMARY AND SECONDARY OUTCOME MEASURES

This study individually tracked patients over a 3-year study period and identified those who were subsequently diagnosed with IDA following the index date.

RESULTS

The incidence rates of IDA in the study and control groups were 1.66 (95% CI CI 1.45 to 1.86) and 1.01 per 100 person-years (95% CI 0.78 to 1.25), respectively. Furthermore, proportional Cox regression revealed an HR of 1.62 (95% CI 1.24 to 2.12) for IDA in the study group after adjusting for patients' age, monthly income, geographic location, residential urbanisation level and incidence of hyperlipidaemia, diabetes, hypertension, coronary heart disease, inflammatory bowel disease, other cancers and gastrointestinal bleeding.

CONCLUSION

Compared with its non-use among patients with prostate cancer, ADT use was associated with a higher risk of IDA.

How might financial pressures have impacted brachytherapy? A proposed narrative to explain the declines in cervical and prostate brachytherapy utilization

Rates of brachytherapy administration in the United States have declined for both cervical and prostate cancers, and we argue that the available facts suggest financial considerations are a major contributor to this issue. In this narrative, we discuss financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, consider other proposed influences, and provide suggestions for future research to understand the scope of the issue.

Management of Metastatic Hormone-Sensitive Prostate Cancer (mHSPC): an Evolving Treatment Paradigm

OPINION STATEMENT

Combination systemic therapy is now standard of care for all men with metastatic, hormone-sensitive prostate cancer (mHSPC). Patients with mHSPC should be treated with standard androgen deprivation therapy (ADT) and abiraterone acetate with prednisone or docetaxel (chemohormoanl therapy) unless there are contraindications to combination therapy. Based on the Chemohormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED) study subgroup analysis, chemohormonal therapy may be most beneficial in men with high-volume disease burden, as men with low-volume metastatic disease do not appear to experience a survival benefit with chemohormonal therapy, while abiraterone in combination with ADT appears to be beneficial across both disease volume subgroups. Decisions regarding whether to use chemohormonal therapy or abiraterone and ADT for men with mHSPC should integrate consideration of volume of disease burden, quality of life effects, duration of therapy, and patient preferences for treatment as there is no formally powered prospective head-to-head comparison of these options demonstrating superiority of one approach over the other. Treatment of the primary tumor with radiation should be considered in men with de novo low-volume metastatic disease as radiation is associated with prolonged survival and a tolerable toxicity profile. Men with de novo high-volume metastatic disease do not appear to have improved survival with radiation of the primary tumor. Numerous clinical trials are ongoing to evaluate treatment approaches that may benefit men with mHSPC. Radical prostatectomy in men with mHSPC in combination with optimal systemic therapy is currently being assessed in a clinical trial, but should not be considered outside of a clinical trial. Metastasis-directed therapy with radiotherapy directed at metastatic lesions is still investigational, but can be considered in clinical trials in men with oligometastatic disease. Multiple studies are enrolling worldwide for men with mHSPC, and these should be considered for all interested patients.

Urologist Practice Structure and Spending for Prostate Cancer Care

OBJECTIVE

To investigate the impact of urologist practice structure on health care spending for men with prostate cancer. We hypothesize that 3 elements of urologist practice structure may influence spending for prostate cancer care: urologist participation within a multispecialty group (MSG), practice size among single specialty urology groups, and intensity-modulated radiation therapy (IMRT) ownership.

MATERIALS AND METHODS

We used a 20% sample of fee-for-service Medicare beneficiaries to identify men newly diagnosed with prostate cancer between 2011 and 2014. We identified each man's urologist and used data from the Healthcare Relational Spheres provider files to identify practice type, size, and IMRT ownership for each urologist. We then fit generalized linear mixed models to estimate the association between these practice features and Medicare payments in the year after diagnosis. All models were adjusted for patient and healthcare market characteristics.

RESULTS

We identified 35,929 men with newly diagnosed prostate cancer who were treated by 6381 urologists. Medicare payments for men with newly diagnosed prostate cancer were significantly lower in MSGs ($19,181 v. $22,366 large single specialty group, P < 0.001) and significantly higher among practices with IMRT ownership ($23,801 v. $20,162 for non-owners, P < 0.001). These differences persisted in sensitivity analyses including only men treated with radiotherapy and examining only prostate cancer-related claims.

CONCLUSION

Urologist practice structure is associated with payments for prostate cancer care. MSGs had the lowest Medicare payments per episode of prostate cancer care while groups with IMRT ownership had the highest.

Cost-Effectiveness of Adding Androgen Deprivation Therapy to Radiation Therapy for Men with Advanced Prostate Cancer from a U.S. Payer's Perspective

BACKGROUND

No study has investigated the cost and effectiveness of androgen deprivation therapy (ADT) and other curative treatment therapies among the Medicare population, and no study has taken into consideration the long-term side effects associated with ADT.

OBJECTIVE

To examine if adding ADT was cost-effective when accounting for ADT-related long-term side effects in men with prostate cancer.

METHODS

For this cost-utility analysis, we used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to estimate and compare patient survival, costs from a health payer's perspective, and cost-effectiveness of 3 treatment modalities for advanced prostate cancer patients, including radiation therapy, radiation plus ADT, and active surveillance. We also estimated quality-adjusted life-years (QALYs) by assigning appropriate health state utility values obtained from the literature for each phase of care and for long-term side effects. Propensity score matching was used to control for bias and confounding that were inherent to the observational study design.

RESULTS

Adding ADT to radiation therapy increased median patient survival by 0.71 years. The incremental cost-effectiveness ratio (ICER) for radiation plus ADT versus radiation alone was $63,049 and $295,995 per mean life-year gained for radiation compared with active surveillance, respectively. Treatment-associated adverse side effects substantially reduced QALYs gained. Compared with radiation only, the incremental cost of radiation plus ADT was $127,900 per mean QALY and was nearly 80% cost-effective at a willingness-to-pay threshold of $210,000 per QALY.

CONCLUSIONS

Despite ADT-associated costs and long-term side effects, compared with radiation alone, radiation plus ADT was cost-effective at $127,900 per QALY.

DISCLOSURES

This research was supported in part by the Cancer Prevention Research Institute of Texas (grant nos. RP130051 and RP170668). The authors declare that there are no conflicts of interest.

Practice Patterns for Older Adult Patients With Advanced Cancer: Physician Office Versus Hospital Outpatient Setting

PURPOSE

A shift in outpatient oncology care from the physician's office to hospital outpatient settings has generated interest in the effect of practice setting on outcomes. Our objective was to examine whether medical oncologists' prescribing of drugs and services for older adult patients with advanced cancer is used more in physicians' offices compared with hospital outpatient departments.

METHODS

This was a retrospective comparative study. SEER-Medicare data (2004 to 2011) were used to identify Medicare beneficiaries diagnosed with advanced breast, colon, esophagus, non-small-cell lung, pancreatic, or stomach cancer. Between physicians' offices and hospital outpatient departments, we compared use of selected likely low-value supportive drugs, low-value therapeutic drugs, chemotherapy-related hospitalizations, and hospice. We used hierarchical modeling to assess differences between settings to account for correlation within physicians.

RESULTS

Compared with patients treated in a hospital outpatient department, those treated in a physician's office setting were more likely to receive erythropoiesis-stimulating agents (odds ratio, 1.72; 95% CI, 1.53 to 1.94) and granulocyte colony-stimulating factors (odds ratio, 1.28; 95% CI, 1.18 to 1.38). For combination chemotherapy and nanoparticle albumin-bound-paclitaxel in patients with breast cancer, there was a trend toward higher use in physicians' offices, although this was not statistically significant. Chemotherapy-related hospitalizations and hospice did not vary by setting.

CONCLUSION

We found somewhat higher use of several drugs for patients with advanced cancer in physicians' office settings compared with hospital outpatient departments. Findings support research to dissect the mechanisms through which setting might influence physicians' behavior.

De-implementation of low value castration for men with prostate cancer: protocol for a theory-based, mixed methods approach to minimizing low value androgen deprivation therapy (DeADT)

Background

Men with prostate cancer are often castrated with long-acting injectable drugs termed androgen deprivation therapy (ADT). Although many benefit, ADT is also used in patients with little or nothing to gain. The best ways to stop this practice are unknown, and range from blunt pharmacy restrictions to informed decision-making. This study will refine and pilot two different de-implementation strategies for reducing ADT use among those unlikely to benefit in preparation for a comparative effectiveness trial.

Methods/design

This innovative mixed methods research program has three aims. Aim 1: To assess preferences and barriers for de-implementation of chemical castration in prostate cancer. Guided by the theoretical domains framework (TDF), urologists and patients from facilities with the highest and lowest castration rates across the VA will be interviewed to identify key preferences and de-implementation barriers for reducing castration as prostate cancer treatment. This qualitative work will inform Aim 2 while gathering rich information for two proposed pilot intervention strategies. Aim 2: To use a discrete choice experiment (DCE), a novel barrier prioritization approach, for de-implementation strategy tailoring. The investigators will conduct national surveys of urologists to prioritize key barriers identified in Aim 1 for stopping incident castration as localized prostate cancer treatment using a DCE experiment design. These quantitative results will identify the most important barriers to be addressed through tailoring of two pilot de-implementation strategies in preparation for Aim 3 piloting. Aim 3: To pilot two tailored de-implementation strategies to reduce castration as localized prostate cancer treatment. Building on findings from Aims 1 and 2, two de-implementation strategies will be piloted. One strategy will focus on formulary restriction at the organizational level and the other on physician/patient informed decision-making at different facilities. Outcomes will include acceptability, feasibility, and scalability in preparation for an effectiveness trial comparing these two widely varying de-implementation strategies.

Discussion

Our innovative approach to de-implementation strategy development is directly aligned with state-of-the-art complex implementation intervention development and implementation science. This work will broadly advance de-implementation science for low value cancer care, and foster participation in our de-implementation evaluation trial by addressing barriers, facilitators, and concerns through pilot tailoring.

Trial registration

ClinicalTrials.gov Identifier: NCT03579680, First Posted July 6, 2018.

Neoadjuvant Androgen Deprivation Therapy Prior to Radical Prostatectomy: Recent Trends in Utilization and Association with Postoperative Surgical Margin Status

PURPOSE

In this study, we sought to describe the contemporary trends in utilization of neoadjuvant androgen deprivation therapy (ADT). As a secondary endpoint, we assessed the community-level effect of neoadjuvant ADT on positive surgical margins after radical prostatectomy (RP).

METHODS

Using the National Cancer Database (2004-2014), we identified patients with clinically localized prostate cancer (PCa) [cT1-4N0M0] treated with RP. The estimated annual percentage change (EAPC) mixed linear regression methodology was used for temporal trend analysis of neoadjuvant ADT. Observed differences in baseline characteristics between patients treated with neoadjuvant ADT versus those who were not were then controlled for using an inverse probability of treatment weighting (IPTW) approach. IPTW-adjusted analyses were then performed to examine the odds of positive surgical margins.

RESULTS

Overall, 8184 (2.12%) and 377,843 (97.88%) individuals with PCa were treated with neoadjuvant ADT prior to RP versus RP only, respectively. There was a consistent trend in decreasing use of neoadjuvant ADT over time, with a nadir observed in 2011 [EAPC - 8.08; 95% confidence interval (CI) - 11.7 to - 4.32; p < 0.05]. In IPTW-adjusted analyses, the odds of positive surgical margins were lower in patients receiving neoadjuvant ADT with low-risk [odds ratio (OR) 0.65; 95% CI 0.51-0.84; p < 0.001] and intermediate-risk [OR 0.76; 95% CI 0.69-0.85; p < 0.001] PCa.

CONCLUSIONS

After a period of steady decline, there appears to be a modest trend towards increased utilization of neoadjuvant ADT in more recent years. We found an association between neoadjuvant ADT and decreased odds of positive surgical margins among low- and intermediate-risk patients.

Race and Time to Receipt of Androgen Deprivation Therapy Among Men With Metastatic Prostate Cancer

BACKGROUND

The Medicare Modernization Act (MMA) drastically reduced reimbursement for androgen deprivation therapy (ADT) in 2005. One unintended consequence of the MMA may be an increase in the racial disparities in receipt of ADT. Given these policy changes, it becomes increasingly important to assess racial disparities in timely receipt of ADT.

METHODS

The purpose of this study is to evaluate the associations between race and median time to receipt of ADT among men with metastatic prostate cancer before and after the passage of the MMA. A population-based retrospective cohort was created from the Surveillance, Epidemiology, and End Results-Medicare.

RESULTS

A total of 1,846 African-American and 9,462 Caucasian men diagnosed with metastatic prostate cancer from 2000 through 2011 were included. An accelerated failure time regression model was used to examine factors associated with racial differences in median time to receipt of ADT. Results indicate that African-American men had a longer median time to receipt of ADT both before the MMA (Time Ratio (TR): 1.15; 95% Confidence Interval (CI) [1.05, 1.27]) and after the MMA (TR: 1.29; 95% CI [1.10, 1.53]) as compared to Caucasian men. In addition to race, men residing in South had longer median time to receipt of ADT (TR: 1.26, 1.52; 95% CI [1.01, 1.52; 1.24, 1.87] before and after MMA, respectively) compared to the Northeast region.

CONCLUSION

Considering the palliative benefits of ADT, it is important to develop effective strategies to address racial differences in receipt of treatment for metastatic prostate cancer.

Risks of Major Long-Term Side Effects Associated with Androgen-Deprivation Therapy in Men with Prostate Cancer

STUDY OBJECTIVE

To examine the risks and compare the occurrences of major long-term side effects (sexual dysfunction, bone fractures, diabetes, cardiovascular morbidity, acute myocardial infarction [MI], and dementia) in patients with prostate cancer who received androgen-deprivation therapy (ADT) with those who did not.

DESIGN

Propensity score-matched retrospective cohort study using Medicare claims data.

DATA SOURCE

National Cancer Institute's Surveillance, Epidemiology, and End Results Program-Medicare linked database.

PATIENTS

A total of 201,797 patients 66 years or older who were diagnosed with any stage of prostate cancer between 1992 and 2009; of these, 94,528 patients received ADT; 107,269 patients did not.

MEASUREMENTS AND MAIN RESULTS

We identified receipt of ADT and number of claims for ADT, and ascertained the long-term treatment-related side effects that occurred during 19 years of follow-up, from 1992-2010, from Medicare claims data. Cox proportional hazards models were used to estimate the incidences and hazard ratios (HRs) of newly developed side effects. Among all potential long-term side effects, the risk of bone fractures was highest (HR 1.39, 95% confidence interval [CI] 1.35-1.43), followed by diabetes (HR 1.21, 95% CI 1.18-1.24), dementia (HR 1.16, 95% CI 1.13-1.20), coronary heart disease (HR 1.12, 95% CI 1.09-1.14), and acute MI (HR 1.11, 95% CI 1.08-1.15) in those who received ADT compared with those who did not. The HRs for bone fractures and diabetes increased steadily as the number of ADT doses increased, indicating a linear trend in the dose-response relationship. Compared with patients who received active surveillance, ADT was associated with a 12% increased risk of sexual dysfunction (HR 1.12, 95% CI 1.05-1.20). The HR for sexual dysfunction increased to 1.68 (95% CI 1.59-1.77) when ADT was combined with radiation therapy and to 3.54 (95% CI 3.26-3.85) when ADT was combined with radiation and surgery.

CONCLUSION

The results of this study demonstrated that in men with prostate cancer, receipt of ADT was associated with higher risks of bone fractures, diabetes, dementia, coronary heart disease, acute MI, and sexual dysfunction than in those who did not receive ADT.

Association of androgen deprivation therapy with thromboembolic events in patients with prostate cancer: a systematic review and meta-analysis

BACKGROUND

Whether androgen deprivation therapy (ADT) causes excess thromboembolic events (TEs) in men with prostate cancer (PCa) remains controversial and is the subject of the US Food and Drug Administration safety warning. This study aims to perform a systematic review and meta-analysis on previous studies to determine whether ADT is associated with TEs in men with PCa.

METHODS

Medline, Embase, and Cochrane Library databases were searched for relevant studies. These studies comprised those that compared ADT versus control to treat PCa, reported TEs as outcome, and were published before January 2018. Multivariate adjusted hazard ratios (HRs) and associated 95% confidence intervals (CIs) were calculated using random- or fixed-effects models.

RESULTS

Five retrospective population-based cohort studies involving 170,851 ADT users and 256,704 non-ADT users were identified. Deep venous thrombosis (DVT) was found significantly associated with gonadotropin-releasing hormone (GnRH) agonists alone (HR = 1.47, 95% CI: 1.07-2.03; P = 0.017; I² = 96.3%), GnRH agonists plus oral antiandrogen (AA) (HR = 2.55, 95% CI: 2.21-2.94; P < 0.001; I² = 0.0%), and AA alone (HR = 1.49, 95% CI: 1.13-1.96; P = 0.004; I² = 0.0%), but not with orchiectomy (HR = 1.80, 95% CI: 0.93-3.47; P = 0.079; I² = 94.8%). In addition, pulmonary embolism (PE) was significantly associated with GnRH agonists alone (HR = 2.26, 95% CI: 1.78-2.86; P < 0.001; I² was unavailable) and orchiectomy (HR = 2.12, 95% CI: 1.44-3.11; P < 0.001; I² = 57.2%). This relationship was also supported with subgroup analyses based on different continents and races.

CONCLUSIONS

GnRH agonists alone, GnRH plus AA, and AA alone cause excess DVT in men with PCa after controlling the demographic and disease characteristics and other confounding factors, although statistically significant difference was not observed in orchiectomy group. Additionally, GnRH agonists alone and orchiectomy can increase the incidence of PE.

Racial, Socioeconomic, and Geographic Disparities in the Receipt, Timing to Initiation, and Duration of Adjuvant Androgen Deprivation Therapy in Men with Prostate Cancer

OBJECTIVE

This retrospective cohort study aims to examine the receipt, timing to initiation, and duration of androgen deprivation therapy (ADT) in men with prostate cancer by race/ethnicity, socioeconomic status, and geographic location.

METHODS

The study population are patients from Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, who were 66 years or older and newly diagnosed with stage III and IV prostate cancer in 1992-2009 and underwent radiation therapy, where ADT was proven to be highly beneficial and its use was considered as most appropriate (n = 12,170). We use logistic regression to examine the receipt of ADT and linear regression to study factors associated with time to ADT initiation while controlling for baseline characteristics.

RESULTS

Overall, 77% of eligible patients received at least one form of ADT in combination with radiation therapy, of which 12% underwent orchiectomy and the rest received ADT, and 77.2% of non-Hispanic white and 80.7% of Hispanic patients received ADT compared to 73.8% of non-Hispanic black. After adjustment for demographic and tumor characteristics, black men and men of other races are less likely to receive ADT compared to white counterparts (OR = 0.64 and 0.74, respectively). The median time from cancer diagnosis to ADT initiation is 2 months. Once initiated, men received a median of seven drug injections. After controlling for covariates, race/ethnicity and geographic location (SEER areas) are associated with early initiation of therapy. White, Hispanic men and men living in the South initiate ADT earlier.

CONCLUSION

Significant racial disparities exist in the receipt and use of this highly beneficial therapy, and there are geographic variations in the utilization of this therapy.

Implementation science theories to inform efforts for de-implementation of urologic oncology care practices resulting in overuse and misuse

The field of implementation science has been conventionally applied in the context of increasing the application of evidence-based practices into clinical care, given evidence of underusage of appropriate interventions in many settings. Increasingly, however, there is recognition of the potential for similar frameworks to inform efforts to reduce the application of ineffective or potentially harmful practices. In this article, we provide some examples of clinical scenarios in which the quality problem may be overuse and misuse, and review relevant theories and frameworks that may inform improvement activities.

Treatment trends and Medicare reimbursements for localized prostate cancer in elderly patients

INTRODUCTION

The absolute and proportional numbers of elderly patients diagnosed with localized prostate cancer (PCa) are on the rise. We examined treatment trends and reimbursement figures in localized PCa patients aged ≥80 years.

METHODS

Between 2000 and 2008, we identified 30 217 localized PCa patients aged ≥80 years in Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Alternative treatment modalities consisted of conservative management (CM), radiation therapy (RT), radical prostatectomy (RP), and primary androgen-deprivation therapy (PADT). For all four modalities, utilization and reimbursements were examined.

RESULTS

PADT was the most frequently used treatment modality between 2000 and 2005. CM became the dominant treatment modality from 2006-2008. RP rates were marginal. RT ranked third, and its annual rate increased from 20.77% in 2000 to 29.13% in 2008. Median individual reimbursement of RT was highest and ranged from $29 343 in 2000 to $31 090 in 2008, followed by RP (from $20 560 in 2000 to $19 580 in 2008), PADT (from $18 901 in 2000 to $8000 in 2008), and CM (from $1824 in 2000 to $1938 in 2008). RT contributed to most of the cumulative annual reimbursements from 2003 (49.24%) to 2008 (72.97%). PADT ranked first from 2000 (54.56%) to 2002 (50.49%), but decreased by 19.40% in 2008. CM's contribution increased from 4.42% in 2000 to 6.96% in 2008. RP's share of reimbursements was stable during the study period.

CONCLUSIONS

Our results, focusing on localized PCa treatment in patients aged ≥80 years, showed an important increase in rates, median cost, and proportion of cumulative cost related to RT.

An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015

BACKGROUND

Analyses of skin cancer procedures adjusted for population changes are needed.

OBJECTIVE

To describe trends in skin cancer-related biopsies and procedures in Medicare beneficiaries.

METHODS

An ecological study of Medicare claims for skin biopsies and skin cancer procedures in 2000 to 2015.

RESULTS

Biopsies increased 142%, and skin cancer procedures increased 56%. Mohs micrographic surgery (MMS) utilization increased on the head/neck, hands/feet, and genitalia (increasing from 11% to 27% of all treatment procedures) but was low on the trunk/extremities (increasing from 1% to 4%). Adjusted for increased Medicare enrollment (+36%) between 2000 and 2015, the number of biopsies and MMS procedures performed per 1000 beneficiaries increased (from 56 to 99 and from 5 to 15, respectively), whereas the number of excisions and destructions changed minimally (from 18 to 16 and from 19 to 18, respectively). Growth in biopsies and MMS procedures slowed between each time period studied: 4.3 additional biopsies per year and 0.9 additional MMS procedures per year per 1000 beneficiaries between 2000 and 2007, 2.2 and 0.5 more between 2008 and 2011, and 0.5 and 0.3 more between 2012 and 2015, respectively.

LIMITATIONS

Medicare claims-level data do not provide patient-level or nonsurgical treatment information.

CONCLUSIONS

The increased number of skin cancer procedures performed was largely the result of Medicare population growth over time. MMS utilization increased primarily on high- and medium-risk and functionally and cosmetically significant locations where tissue sparing and maximizing cure are critical.

Reimbursement and use of intensity-modulated radiation therapy for prostate cancer

The use of intensity-modulated radiation therapy (IMRT) for prostate cancer increased through the mid-2000s, in association with acquisition of the devices by large urology groups. More recently, reimbursement for IMRT in the office setting (generally representing freestanding facilities owned by physicians) has been declining. The aim of the study was to examine trends in IMRT use and related payments in the office versus hospital outpatient setting over time.In this retrospective cohort study, a total of 66,967 men aged 66 years or older, with newly diagnosed prostate cancer from 2007 through 2012 were identified in a 20% national sample of Medicare claims. IMRT use in the office versus hospital outpatient setting was examined over time, adjusted for patient characteristics using multivariable logistic regression models. Mean reimbursement for IMRT treatments and total IMRT-related payments were plotted by year.IMRT use increased from 28.6% to 38.0% of newly diagnosed men with prostate cancer over the study period, exclusively related to growth in the office setting. In particular, use in the office setting increased from 13.2% in 2007 to 22.1%, whereas use in the hospital outpatient setting remained essentially steady throughout the period around 15%. During the same period mean reimbursement for IMRT in the office setting declined from $504 per individual radiation treatment to $381, whereas it increased from $283 to $380 in the hospital outpatient setting. However, total IMRT-related payments in the office setting increased through 2011 due to increased utilization, falling only in 2012 (to $35.7 million from $48.3 million in 2011) related both to continued declines in reimbursement and a large reduction in new cases of prostate cancer.In conclusion, use of IMRT in the physician office setting in men diagnosed with prostate cancer has continued to increase in the face of declining reimbursement. Total payments for IMRT fell only in 2012, following a substantial reduction in new cases of prostate cancer.

Low rates of androgen deprivation therapy use with salvage radiation therapy in patients with prostate cancer after radical prostatectomy

OBJECTIVE

The RTOG 9601 and GETUG-AFU 16 randomized controlled trials demonstrated that the addition of androgen deprivation therapy (ADT) to salvage radiation therapy (SRT) improves progression-free and, for RTOG 9601, overall survival. We examined national trends in the use of ADT with SRT.

MATERIALS AND METHODS

Of the 484,009 patients in the National Cancer Database from 2004 to 2012 with localized or locally advanced prostate cancer treated with radical prostatectomy (RP), 4,200 men received SRT (≥6mo after surgery). We used Pearson's chi-squared test to evaluate changes in ADT use, and multiple logistic regression to examine predictors of ADT use.

RESULTS

Overall, 32.1% of SRT patients received ADT, which increased after initial results of RTOG 9601 showed an improvement in metastasis-free survival in 2010 (28.5% in 2008/2009 vs. 34.5% in 2011/2012, P = 0.006). Predictors of ADT use include presurgery prostate-specific antigen>20ng/ml vs.<10ng/ml (adjusted odds ratio [AOR] = 1.34, P = 0.002; 36.7% vs. 29.6%); positive vs. negative margins (AOR = 1.29, P = 0.001; 34.9% vs. 27.8%); Gleason 3+4 (AOR = 1.53; 21.3%), Gleason 4+3 (AOR = 2.40; 32.0%), or Gleason 8 to 10 (AOR = 4.49; 49.2%) vs. Gleason 2 to 6 (P≤0.005 for all; 13.2%); and pathologic T3a (AOR = 1.46; 30.9%), T3b (AOR = 2.50; 47.6%), or T4 (AOR = 4.14; 60.9%) vs. T2 (P<0.001 for all; 19.1%). Starting SRT 12 to 23.9 months (AOR = 0.69; 23.2%) or≥24 months (AOR = 0.25; 8.0%) after RP was associated with decreased odds of ADT use vs. starting SRT 6 to 8.9 months after RP (P≤0.002 for both; 35.0%).

CONCLUSION

Although less than one-third of SRT patients from the study era received ADT, there is evidence that physicians and patients have begun slowly adopting this practice with the 2010 reporting of a decrease in the cumulative incidence of metastases with the addition of ADT to SRT. Given the newly reported survival benefit of RTOG 9601, additional work will be necessary to identify which patients benefit the most from the use of ADT with SRT to individualize treatment.

Use of the Medicare database in epidemiologic and health services research: a valuable source of real-world evidence on the older and disabled populations in the US

Medicare is the federal health insurance program for individuals in the US who are aged ≥65 years, select individuals with disabilities aged <65 years, and individuals with end-stage renal disease. The Centers for Medicare and Medicaid Services grants researchers access to Medicare administrative claims databases for epidemiologic and health outcomes research. The data cover beneficiaries’ encounters with the health care system and receipt of therapeutic interventions, including medications, procedures, and services. Medicare data have been used to describe patterns of morbidity and mortality, describe burden of disease, compare effectiveness of pharmacologic therapies, examine cost of care, evaluate the effects of provider practices on the delivery of care and patient outcomes, and explore the health impacts of important Medicare policy changes. Considering that the vast majority of US citizens ≥65 years of age have Medicare insurance, analyses of Medicare data are now essential for understanding the provision of health care among older individuals in the US and are critical for providing real-world evidence to guide decision makers. This review is designed to provide researchers with a summary of Medicare data, including the types of data that are captured, and how they may be used in epidemiologic and health outcomes research. We highlight strengths, limitations, and key considerations when designing a study using Medicare data. Additionally, we illustrate the potential impact that Centers for Medicare and Medicaid Services policy changes may have on data collection, coding, and ultimately on findings derived from the data.