Acquisition of intensity-modulated radiation therapy (IMRT) services by private urology practices in the USA is associated with significantly more IMRT self-referral than preownership referral for newly diagnosed nonmetastatic prostate cancer treatment. These findings, published in the New England Journal of Medicine, have rekindled debate about the self-referral of ancillary services eligible for reimbursement and the potential conflict between patient benefit and financial recompense.

For the study, Jean Mitchell of Georgetown University analysed Medicare claims data from 2005 to 2010 for over 40,000 men. Preownership and postownership treatment rates were compared in 35 private practices that acquired IMRT services during this period, with equivalent comparisons in 35 geographically matched private practices without IMRT service self-referral. A significant increase in IMRT treatment (from 13.1% of all treatment to 32.3%) accompanied IMRT ownership, with reductions in both brachytherapy (18.6% to 5.6%) and ADT (16.5% to 8.4%). In the control group, treatment with IMRT (14.3% to 15.6%) and brachytherapy (18.9% to 17.9%) did not change significantly, unlike ADT use, which fell (15.6% to 11.4%).

A further comparison involving 11 self-referring practices and 11 National Comprehensive Cancer Network centres showed a similar pattern of increased IMRT delivery with self-referral (from 9.0% to 42.0%) corresponding to reductions in all other treatments. No significant changes in treatment rates were found in the control centres.

Publication of these results presaged an unedifying war of words between groups representing urologists and oncologists. The AUA disputed the scientific basis and independence of the peer-reviewed article, while ASTRO, who provided funding for the research, called for an end to self-referral for radiation therapy.

...financial incentives appear to influence ... recommendations of self-referring urologists

This research raises serious concerns about the potential overuse of IMRT, notably in elderly patients who might suffer from radiation toxicity in the short term without experiencing long-term benefits. “The findings suggest that financial incentives appear to influence the referral recommendations of self-referring urologists,” argues Mitchell. If it is indeed the case, then all interested parties should help to find a way to recalibrate the use of IMRT in the best interests of all patients.