A new study appearing in The New England Journal of Medicine and funded by the American Cancer Society identifies a substantial decline in the use of androgen deprivation therapy (ADT) in men with prostate cancer following reductions in physician reimbursement from Medicare as a result of the Medicare Modernization Act. The study, led by Vahakn B. Shahinian, M.D., of the University of Michigan, Ann Arbor, found reductions in ADT use were most dramatic in men for whom the use of the medication was not compatible with the evidence. Using the Surveillance, Epidemiology, and End Results (SEER) Medicare database, they identified 54,925 men who received a diagnosis of incident prostate cancer between 2003 through 2005. They divided them into groups according to the strength of the indication for ADT use and by year of diagnosis. They found the rate of inappropriate use of ADT declined substantially during the study period, from 38.7% in 2003 to 30.6% in 2004 to 25.7% in 2005. There was no decrease in the appropriate use of adjuvant ADT. They conclude that changes in the Medicare reimbursement policy in 2004 and 2005 were associated with reductions in ADT use, particularly among men for whom the benefits of such therapy were unclear.
Below are comments about the study’s findings from Otis W. Brawley, M.D., chief medical officer.
“Androgen deprivation therapy (ADT) is a hormonal therapy that is FDA approved and appropriately used for some types of prostate cancer. The drug carries a high price tag, and throughout the 1990s, physician reimbursement policy made administration of these drugs very profitable, primarily to urologists and medical oncologists. Studies have shown that reimbursement for ADT was 40% of all Medicare payments to some urology practices in the late 1990s. Total Medicare costs for these drugs in 2000 were about $1 billion. At that time nearly half of all men with prostate cancer were being administered one of these drugs.
“In 2004, Medicare decreased reimbursement for the class of drugs. This decreased the profits that physicians made by prescribing and administering them. For the new study, researchers merged Medicare and NCI cancer registry databases, and were able to identify changes in practice patterns that coincided with the change in reimbursement policy. They determined for which men ADT was appropriate and those for whom it was not. They determined that a large number of men whose disease was not appropriate for ADT therapy were treated with these drugs during the era of high reimbursement, and that there was a dramatic decline in the inappropriate usage of these drugs when reimbursement decreased. Notably, appropriate use of ADT did not change substantially over time.
“It should be noted that the FDA has issued a warning that this class of drugs has significant side effects. The drugs can cause muscle wasting, osteoporosis, diabetes, cardiovascular disease, and stroke. Indeed, the significant increased risk of cardiovascular death associated with these drugs is a tremendous concern as it may be a significant contributor to premature death among men with prostate cancer. It is also important to note that ADT remains a useful treatment for the appropriate patient with the appropriate type of prostate cancer.”