Patterns in the Treatment of Intermediate and High Risk Localized Prostate Cancer

Transcription

1 Patterns in the Treatment of Intermediate and High Risk Localized Prostate Cancer Jonathan E. Heinlen, M.D. Stephenson Oklahoma Cancer Center University of Oklahoma Health Sciences Center

2 Disclosures I have no relevant financial disclosures

3 Why Patterns? What do you prefer for treating prostate cancer of a particular clinical status (i.e. stage, grade, PSA) Why do you prefer it? Evidence-based medicine! What else influences you? What influences others? What influences your patients?

4 Who cares?

5 Conspiracy theory? So.does pharma influence the treatment of localized prostate cancer? Probably not directly but we need to better understand how these decisions are made.

6 You have prostate cancer

7 Your PATIENT has prostate cancer Source ClevelandHealth.com

8 The Equivalency Myth RP vs. XRT vs. Brachytherapy JAMA 1998 (D Amico) Compared 1872 men treated for low, intermediate, or high risk disease 5 year PSA outcomes determined RP and XRT equivalent in all risk groups BT only equivalent in low risk. Protect randomization of 1643 men 10 years in, no difference among surveillance, prostatectomy, EBRT BUT Differences in QoL

9 Why we like prostatectomy

10 Prostatectomy for Intermediate Risk Bill-Axelson et.al. NEJM 2014

11 Prostatectomy Intermediate v. High Bill-Axelson et.al. NEJM 2014

12 Prostatectomy Metastasis and ADT Bill-Axelson et.al. NEJM 2014

13 Prostatectomy is what we do Outcomes are generally good Patients are generally happy We get paid to do it Although this is somewhat inarguable shouldn t this be the same everywhere?

14 Unwarranted Variation Variation in medical practice pattern that cannot be explained by: Illness Medical Need Evidence based care E.g. Medicare spending in 2003 was 2.5x greater per enrollee in Miami than in Minneapolis Adjusted for age, sex, race Blamed on inconsistency in adherence to evidence based medicine Sipkoff 2003

15 Variation in Prostate Cancer Care Time Geographic Based on specialty Provider-to-provider Is unwarranted variation always bad?

16 Temporal Variation Cooperberg, JCO 2010

17 Temporal Variation i3 Registry Cooperberg, PCPD 2015

18 Centralization of surgery over time Barocas et.al, J Urol 2012

19 Time trends in locally advanced prostate cancer Scardino et.al. BJUI 2012

20 Geographic Variation Healthcare Financing Administration Region Brachy (%) Brch+XRT (%) RRP (%) RRP + XRT (%) XRT(%) Midwest Northeast South West Other Litwin, Cancer 2000

21 Geographic Variation VAMC, No. Noncurative Treatment (%) No. Surgery (%) No. Radiation Therapy (%) Geographic region: Northeast 2,431 (45) 1,271 (24) 1,684 (31) South 2,556 (48) 1,384 (26) 1,407 (26) Midwest 1,173 (47) 570 (23) 762 (30) West 1,565 (50) 789 (25) 760 (24) Litwin, J Urol 2004

22 Geographic Variation SEER Regions 95-99

23 Geographic Variation - County Heinlen, Ruel; 2013

24 Geographic Variation - County Heinlen, Ruel; 2013

25 Treatment Choice by Residency Location Doescher et.al., Cancer 2013

26 Demographics of Counties by XRT Usage Quartile XRT Usage (% of patients in county) Median Population Median # of Cases Cases/Pop Median Household Income 1 9% 193, $53, % 244, $52, % 371, $52, % 471, $57,960 Heinlen, AUA National Meeting 2014

27 Geographic Availability of Urologists Cooperberg et.al. PCPD 2015

28 Demographics Associated with Treatment (Any) Cooperberg et.al., PCPD 2015

29 International Incidence of Prostate Cancer Bray et.al. EAU 2012

30 International Age-Adjusted Mortality CaP Bray et.al. EAU 2012

31 Incidence versus Mortality Bray et.al. EAU 2012

32 Provider Variation

33 Provider Variation Who you see matters ρ = Proportion of variation attributable to practice site Treatment ρ (all patients) 95% CI ρ (low-risk patients only) 95% CI WW/AS to to 0.37 RP to to 0.42 EBRT to to 0.37 Brachytherapy to to 0.49 Cryotherapy to to 0.91 PADT to to 0.39 NADT to 0.23 Cooperberg JCO 2010

34 Provider Variation Group Integration IPCC Integrated prostate cancer centers (offer urology and RadOnc) HRR Health referral region Time frame (before) (after) The particular group converted in 2005 to an integrated format Bekelman et.al. J Urol, 2013

35 Insurance Status * Ingenix = private insured claims database Cooperberg, PCPD 2015

36 Robotic Prostatectomy Adoption All payers - USA Trinh QD, Eur Urol 2016

37 Robotic Prostatectomy Market Share 52 total hospitals Acquired versus didn t Acquire robot in Wisconsin Nattinger, Cancer, 2011

38 Adoption of Radiation Technology in USA Private insurance only Pan HY et.al. JACR, 2017

39 Replacement of IMRT with Proton Dvorak, JACR 2010

40 Cost of Proton Beam Cost/Fraction Description Code Hospital Based Freestanding Conventional radiation $ $ IMRT $ $ SBRT G0339, G0340, $3, $1, GKRS $8, $1, Proton level I 77520/77522 $ $ Proton level II 77523/77525 $ $ Dvorak, JACR 2010

41 Ramping up Proton Dvorak, JACR 2010

42 Uh Oh Protons Proton therapy was associated with more gastrointestinal morbidity than IMRT. This population-based study suggests that IMRT may be associated with improved disease control without compromising morbidity compared with conformal radiation therapy, although proton therapy does not appear to provide additional benefit. Sheets et.al. JAMA 2012

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44 IMRT and Proton for Prostate Cancer

45 Coverage of Proton Beam Routinely Deny Aetna UHC Blue Cross franchises (Except BCBS Fed) Cigna Cover Medicare Medicaid

46 The Ballad of Proton Beam Massive Capital Investments Aggressive revenue generation needed Mainstream advertising Evangelism where s the data? Bad timing Bull-in-a-china-shop directly into the cost-conscious medicine era Coverage denials Too little too late Meager data collection efforts after the fact Too much trust me it works SBRT???

47 Likelihood of initial Active Surveillance Individual practices in Michigan Miller DC, Eur Urol 2014

48 Active Surveillance in Michigan Miller DC, Eur Urol 2014

49 Graphs are great but What causes variation? How is the decision made?

50 Physician Influence on Decision Underwood, Can J Urol 2010

51 Urologist preferences for high risk CaP in Europe Surceti et.al. BJUI, 2015

52 Patient Preference vs Urologist Preference Ubel et.al., MDM 2017

53 What Urologists Recommend Ubel et.al., MDM 2017

54 Does Patient Preference Change the Recommendation? Ubel et.al., MDM 2017

55 Factors influencing PATIENT preference Biological (Grade, stage of disease) ANXIETY not necessarily linked to biology PSA level Demographics (Race, age, etc) Marital status

56 Reducing Variation Starts with Urologists Adherence to guidelines Minimize conflicts of interest Inquire about patient preferences Recommend consultation in patients who are uncertain Avoid pressuring a decision, especially in intermediate risk Ends with insurance/government If we don t fix unwarranted variation, someone else will