Technology diffusion and diagnostic testing for prostate cancer

Impact of a robotic surgical system on treatment choice for men with clinically organ-confined prostate cancer

BACKGROUND

Introducing a new surgical technology may affect behaviors and attitudes of patients and surgeons about clinical practice. Robot-assisted laparoscopic radical prostatectomy (RALP) was approved in 2012 in Japan. We investigated whether the introduction of this system affected the treatment of organ-confined prostate cancer (PCa) and the use of radical prostatectomy (RP).

METHODS

We conducted a retrospective multicenter study on 718 patients with clinically determined organ-confined PCa treated at one of three Japanese academic institutions in 2011 (n = 338) or 2013 (n = 380). Two patient groups formed according to the treatment year were compared regarding the clinical characteristics of PCa, whether referred or screened at our hospital, comorbidities and surgical risk, and choice of primary treatment.

RESULTS

Distribution of PCa risk was not changed by the introduction of RALP. Use of RP increased by 70% (from 127 to 221 cases, p < 0.0001), whereas the number of those undergoing radiotherapy or androgen deprivation therapy decreased irrespective of the disease risk of PCa. Increased use of RP (from 34 to 100 cases) for intermediate- or high-risk PCa patients with mild perioperative risk (American Society of Anesthesiologists score 2) accounted for 70% of the total RP increase, whereas the number of low- or very low-risk PCa patients with high comorbidity scores (Charlson Index ≥ 4) increased from 8 to 25 cases, accounting for 18%. Use of expectant management (active surveillance, watchful waiting) in very low-risk PCa patients was 15% in 2011 and 12% in 2013 (p = 0.791).

CONCLUSIONS

Introduction of a robotic surgical system had little effect on the risk distribution of PCa. Use of RP increased, apparently due to increased indications in patients who are candidates for RP but have mild perioperative risk. Although small, there was an increase in the number of RPs performed on patients with severe comorbidities but with low-risk or very low-risk PCa.

The early adoption of intensity-modulated radiotherapy and stereotactic body radiation treatment among older Medicare beneficiaries with prostate cancer

BACKGROUND

Several new prostate cancer treatments have emerged since 2000, including 2 radiotherapies with similar efficacy at the time of their introduction: intensity-modulated radiotherapy (IMRT) and stereotactic body radiation therapy (SBRT). The objectives of this study were to compare their early adoption patterns and identify factors associated with their use.

METHODS

By using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, patients who received radiation therapy during the 5 years after IMRT introduction (2001-2005) and the 5 years after SBRT introduction (2007-2011) were identified. The outcome of interest was the receipt of new radiation therapy (ie, IMRT or SBRT) compared with the existing standard radiation therapies at that time. The authors fit a series of multivariable, hierarchical logistic regression models accounting for patients nested within health service areas to examine the factors associated with the receipt of new radiation therapy.

RESULTS

During 2001 to 2005, 5680 men (21%) received IMRT compared with standard radiation (n = 21,555). Men who received IMRT were older, had higher grade tumors, and lived in more populated areas (P < .05). During 2007 through 2011, 595 men (2%) received SBRT compared with standard radiation (n = 28,255). Men who received ng SBRT were more likely to be white, had lower grade tumors, lived in more populated areas, and were more likely to live in the Northeast (P < .05). Adjusting for cohort demographic and clinical factors, the early adoption rate for IMRT was substantially higher than that for SBRT (44% vs 4%; P < .01).

CONCLUSIONS

There is a stark contrast in the adoption rates of IMRT and SBRT at the time of their introduction. Further investigation of the nonclinical factors associated with this difference is warranted. Cancer 2017;123:2945-54. © 2017 American Cancer Society.

Technology diffusion and prostate cancer quality of care

OBJECTIVE

To evaluate the association of technological capacity with prostate cancer quality of care. Technological capacity was conceptualized as a market's ability to provide prostate cancer treatment with new technology, including robotic prostatectomy and intensity-modulated radiotherapy (IMRT).

METHODS

In this retrospective cohort study, we used data from the Surveillance, Epidemiology, and End Results-Medicare linked database from 2004 to 2009 to identify men with newly diagnosed prostate cancer (n = 46,274). We measured technological capacity as the number of providers performing robotic prostatectomy or IMRT per population in a health care market. We used multilevel logistic regression analysis to assess the association of technological capacity with receiving quality care according to a set of nationally endorsed quality measures, while adjusting for patient and market characteristics.

RESULTS

Overall, our findings were mixed with only subtle differences in quality of care comparing high-tech with low-tech markets. High robotic prostatectomy capacity was associated with better adherence to some quality measures, such as avoiding unnecessary bone scans (79.8% vs 73.0%; P = .003) and having follow-up with urologists (67.7% vs 62.6%; P = .023). However, for most measures, neither high robotic prostatectomy nor high-IMRT capacity was associated with significant increases in adherence rates. In fact, for 1 measure (treatment by a high-volume provider), high-IMRT capacity was associated with lower performance (23.4% vs 28.5%; P <.001).

CONCLUSION

Our findings suggest that new technology is not clearly associated with higher quality of care. To improve quality, more specific efforts will be needed.

The impact of technology diffusion on treatment for prostate cancer

BACKGROUND

The use of local therapy for prostate cancer may increase because of the perceived advantages of new technologies such as intensity-modulated radiotherapy (IMRT) and robotic prostatectomy.

OBJECTIVE

To examine the association of market-level technological capacity with receipt of local therapy.

DESIGN

Retrospective cohort.

SUBJECTS

Patients with localized prostate cancer who were diagnosed between 2003 and 2007 (n=59,043) from the Surveillance Epidemiology and End Results-Medicare database.

MEASURES

We measured the capacity for delivering treatment with new technology as the number of providers offering robotic prostatectomy or IMRT per population in a market (hospital referral region). The association of this measure with receipt of prostatectomy, radiotherapy, or observation was examined with multinomial logistic regression.

RESULTS

For each 1000 patients diagnosed with prostate cancer, 174 underwent prostatectomy, 490 radiotherapy, and 336 were observed. Markets with high robotic prostatectomy capacity had higher use of prostatectomy (146 vs. 118 per 1000 men, P=0.008) but a trend toward decreased use of radiotherapy (574 vs. 601 per 1000 men, P=0.068), resulting in a stable rate of local therapy. High versus low IMRT capacity did not significantly impact the use of prostatectomy (129 vs. 129 per 1000 men, P=0.947) and radiotherapy (594 vs. 585 per 1000 men, P=0.579).

CONCLUSIONS

Although there was a small shift from radiotherapy to prostatectomy in markets with high robotic prostatectomy capacity, increased capacity for both robotic prostatectomy and IMRT did not change the overall rate of local therapy. Our findings temper concerns that the new technology spurs additional therapy of prostate cancer.