The impact of technology diffusion on treatment for prostate cancer

Abstract

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.

Figure 1

Rates of surgical treatment, radiotherapy, and observation according to market-level technological capacity. The use of radical prostatectomy was significantly higher in markets with high robotic prostatectomy capacity, both among all patients (p=0.008, panel A) and among men 66 to 69 years old (p=0.022, panel B). However, rates of observation remained stable. * Models were adjusted for year, patient characteristics (age, comorbidity, stage, grade, socioeconomic status), and market characteristics (number of urologists, of radiation oncologists, and of hospital beds; managed care penetration; average provider volume in market).

Figure 2

Effect of technological capacity on rates of prostatectomy, radiotherapy, or observation compared with the effects of other covariates. Models were adjusted for year, patient characteristics (age, comorbidity, stage, grade, socioeconomic status), and market characteristics (number of urologists, of radiation oncologists, and of hospital beds; managed care penetration; average provider volume in market). * Denotes p<0.001; tech = technology.

Figure 3

Rates of surgical treatment, radiotherapy, and observation according to market-level technological capacity among men who are least likely to benefit from active treatment (those 70 years and older with D'Amico low-risk disease [n=8,497, panel A] and those 85 years and older [n=3,249, panel B]). Robotic prostatectomy and IMRT capacity did not significantly impact rates of observation (p≥0.226). * Models were adjusted for year, patient characteristics (age, comorbidity, stage, grade, socioeconomic status), and market characteristics (number of urologists, of radiation oncologists, and of hospital beds; managed care penetration; average provider volume in market).