Innovative technology-based approaches to the diagnosis and treatment of prostate cancer (PCa) are not adopted at the same rate or extent across the United States. Studies have documented regional differences in the uptake of novel modalities and techniques such as robotic-assisted radical prostatectomy (RARP),1-3 magnetic resonance imaging (MRI) of the prostate prior to prostate biopsy,4 multiparametric MRI (mpMRI) of the prostate for patients on active surveillance (AS),5 MRI/ultrasound-guided prostate biopsy,6 stereotactic body radiation therapy (SBRT),7,8 and proton beam therapy (PBT).9 Data also reveal significant regional variation in the cost of RARP compared with open surgery.
Adoption of RARP grew rapidly in the United States, with the proportion of radical prostatectomy (RP) cases performed robotically by board-certified urologists rising from 22% of cases in 2003 to 85% in 2013, according to a study published in Urologic Oncology.10 Uptake of RARP varied by region, however. In a study of 221,637 patients who underwent various types of surgery from January 1, 2010, to December 31, 2011 — including 30,345 patients who underwent RP — the proportion of RP cases performed robotically was highest in the West (71.8%), followed by 68.6%, 66.3%, 65.3% in the Midwest, Northeast, and South, respectively, according to study findings published in JAMA Surgery. On multivariable analysis, men in the Midwest, South, and West were 56%, 43%, and 12% more likely to undergo RARP, respectively, compared with those in the Northeast, but the differences were not statistically significant.
The study looked at the effect of regional hospital competition and hospital financial status on the use of robotic-assisted surgery, not just for RP but also for nephrectomy, hysterectomy, and oophorectomy. For all of these operations, robotic-assisted procedures were more likely to be performed in competitive markets.
“Although patient characteristics are associated with the use of robotic-assisted surgery, our findings suggest that regional market forces also influence care,” Graham M. Tooker, MD, of the University of Maryland School of Medicine in Baltimore, and colleagues wrote. “Patients treated at hospitals located in competitive regional markets are more likely to undergo robotic-assisted surgery.”
Cost of RARP vs Open RP
The difference in the cost between RARP and open RP (ORP) also vary by geographic region. In a study of 24,636 RARP and 13,590 ORP patients identified using the National Inpatient Sample (NIS) database (2009 to 2011), RARP was 43.3% more costly in the Midwest, 37.2% more costly in the South, and 39.1% more costly in the West, investigators reported in Clinical Genitourinary Cancer.2 In contrast, the cost of RARP in the Northeast was 12.8% less than for ORP.
“In our study we found that the cost of RARP continues to exceed that of ORP, despite the increase in volume of RARP performed nationwide,” the authors wrote. “Notwithstanding, a regional comparison of costs surprisingly demonstrated that RARP is now a less expensive procedure than ORP in the Northeast region of the United States.”
The authors said they could only speculate that ORP in the Northeast might be reserved for more advanced cases or preference for ORP compared with other regions, and noted that the lower cost of RARP compared with ORP in the Northeast “might not be because of the decreased cost of robotic surgery, but rather might reflect the higher cost of ORP in that region.”2
Regional differences in the added costs of RARP compared with ORP also emerged in a separate study of 83,693 men in the NIS database who underwent RP from 2008 to 2015.3 Of these, 51,363 (61.4%) underwent RARP. Overall, the median total hospital charges were higher for RARP compared with ORP ($11,898 vs $10,162). In adjusted analyses, RARP was associated with higher total hospital charges compared with ORP ($3124 more for each RARP), investigators reported in the World Journal of Urology. Additional charges for RARP vs ORP were highest in the West ($4610), followed by the Midwest ($3278), the South ($2906), and the Northeast ($2216), the investigators reported.
Adoption of prostate MRI prior to biopsy of the gland is among the newer developments for which significant regional disparities exist, according to study data presented during the American Urological Association’s 2020 virtual annual meeting.4 The study, by investigators at Weill Cornell Medical College in New York, New York, included 82,483 men undergoing prostate biopsy who were identified using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. Overall, MRI use prior to biopsy increased from 0.51% in 2008 to 9.15% in 2015 (and from 1.35% to 25.5% among men with a negative prior biopsy), but the odds of undergoing MRI varied geographically. Compared with men undergoing biopsy in the West, those in the Northeast had significant 3.5-fold increased odds and those in the Midwest had significant 40% decreased odds of undergoing prostate MRI, the study found.
“For both prostate diagnosis and treatment, there has been evidence demonstrating significant geographic variation in practice patterns,” said urologic oncologist Jim C. Hu, MD, MPH, a senior author on the study. “For instance, in the 1980s it was shown that radical prostatectomy was more likely to be performed in the West rather than the Northeast. In terms of our study, several factors may influence early adoption of prostate MRI in one region vs another. There were innovators and early adopters of prostate MRI and targeted biopsy in New York City, and others in the region likely were ‘following the leader.’ If early adopters are absent in a particular geographic region, then there will be less pressure on providers there to play catchup.”
Differences in payer coverage for prostate MRI among regions also might influence uptake of prostate MRI, Dr Hu added.
Active Surveillance With mpMRI
The extent to which mpMRI is used for AS also depends on geographic region, according to a study of 9467 men on AS for localized PCa that was diagnosed from 2008 to 2013.5 Of these men, 1289 (14%) had mpMRI scans and 8178 (86%) did not. The proportion of men undergoing mpMRI was 49% and 28% in the West and Northeast, respectively, compared with 14% and 9% in the South and Midwest, Mina M. Fam, MD, of the University of Pittsburgh Medical Center in Pennsylvania, and colleagues reported in Urology. Compared with men in the Northeast, those in the South, Midwest, and West had significant 60%, 65%, and 25% lower odds of undergoing mpMRI, respectively, after adjusting for multiple variables.
The investigators explained that the Northeast and West contain markets with high hospital and physician capacity in close geographic proximity, which results in significant market competition. “This competition may drive increased adoption of new technologies in order to gain a competitive advantage and increase market share,” they wrote. “Thus, the market dynamic of these regions may explain the greater use of mpMRI compared to other regions.”
MRI/Ultrasound-Guided Prostate Biopsy
Geographic disparity is evident as well in the use of MRI/ultrasound-guided prostate biopsy in the diagnosis and staging of PCa, according to the results of a national survey published in Current Urology.6 The survey, which was conducted in 2016, showed that 68% of urologists in the Northeast and 65% of those in the Midwest reported performing MRI/ultrasound-guided biopsy compared with 44% and 53% in the West and South, respectively.
“This may represent differing opinions between institutions on the value of MRI/[ultrasound] technology or may reflect the use of MRI/[ultrasound] fusion biopsy as a means for practices to remain competitive in tighter markets,” the authors noted.
Stereotactic Body Radiation Therapy
Regional differences also have emerged in studies of innovative radiation treatment modalities for PCa. For example, a cohort study of 106,926 patients who received definitive radiation therapy for localized PCa diagnosed from 2010 to 2015 found that patients treated at facilities in the Mid-Atlantic and South Atlantic regions had significant 3.3-fold and 1.7-fold increased odds of receiving SBRT compared with those treated at New England facilities, investigators reported in JAMA Network Open.7
In a separate study of 274,466 men diagnosed with localized PCa from 2004 to 2012 and who received radiation therapy as their initial treatment, investigators found that compared with patients in the South, those in the Northeast had 32% increased odds and those in the Midwest and West had significant 24% and 56% decreased odds of undergoing SBRT, respectively, according to study findings published in Cancer.8
Proton Beam Therapy
PBT is another advanced treatment modality whose diffusion has been greater in some regions than others. Of the 37 PBT centers currently in operation in the United States, according to the National Association for Proton Therapy, 16 are on the East Coast (including 5 in Florida, the most of any state). In contrast, the entire West Coast has only 3 (2 in California and 1 in Washington), and large swaths of the nation between the East and West coasts lack a single center. PBT use for localized PCa has occurred at different rates across the United States, according to an analysis of NCDB data from 2004 to 2013.9 The Southern region experienced the largest proportional increase in PBT use among the various regions in the United States, from 0% in 2004 and 2005 to 7.1% of all external beam radiation therapy (EBRT) cases in 2013, Arya Amina, MD, of the University of Colorado School of Medicine in Aurora, and colleagues reported in Urologic Oncology. In addition, PBT use rose most dramatically in the Southern region, from 0% in 2004 to 44% of all PBT cases nationally in 2013. The Western region had the highest proportion of PBT cases in the United States until 2011. That year, the proportion dropped to 40.2% from 51.3% in 2010, making the Southern region the leader in PBT cases (47.5% of PBT cases).
By 2013, facilities in the West and South contributed a similar proportion of patients treated with PBT: 44.5% and 43.9%, respectively. The Eastern and Midwestern regions contributed 9.7% and 2.0%, respectively, the investigators reported.
“To our knowledge, our analysis is the first assessment of regional PBT usage trends in the United States, showing that the increase in PBT use over the past decade reflects the development of proton therapy centers in the Southern region, while usage in other regions have remained relatively stable,” the authors wrote.
By 2013, nearly half of all PBT for localized PCa was delivered in the Southern region, “likely reflecting a predisposition toward early adoption of available technology and clinical investigation among large academic medical centers in the region.”
J. Kellogg Parsons, MD, MHS, professor of urology at the University of California, San Diego, and author of a 2014 paper in JAMA Surgery titled “Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy,”11 suggests that provider access to new medical technologies and the availability of other specialists needed to use those technologies are among the factors that influence their uptake and could explain regional variation in uptake of innovative approaches to patient care. For example, urologists who want to incorporate mpMRI into their diagnostic approach to PCa need access to both the technological capability to do the scans properly and radiologists with the skill to interpret the scans, Dr Parsons said.
The cost of new technologies for patients and providers also may influence their uptake in a region. For example, he said, urologists often have to demonstrate to third-party payers the clinical evidence supporting prostate MRI to persuade them to cover the procedure. These interactions with insurers are time consuming and pull urologists away from their clinical duties, he said. Regional differences in the extent to which haggling with insurers is a problem could after uptake of prostate MRI in those places, he said.
“Another component of regional variation, and this is pure anecdotal, is how much patients drive preferences,” Dr Parsons said. “You can make an argument, anecdotally, that men with prostate cancer in southern California, where I practice, are going to approach newer technologies and seek out newer technologies in ways that might be different from men [with prostate cancer] in other parts of the country.”
Mark S. Litwin, MD, MPH, professor and chair of urology at David Geffen School of Medicine at the University of California, Los Angeles (UCLA), and professor of health policy and management at the UCLA Fielding School of Public Health, said geographic differences in the diffusion of new medical technologies mostly relates to physician factors, such as willingness and wherewithal to learn a new surgical or diagnostic technique. “It really comes down in part to just how user-friendly this technology is for the doctors who are responsible for operationalizing it,” Dr Litwin said.
Other physician factors include physician age and how much time has elapsed since physicians received their medical training. “The earlier they are out from their training, the more open they are to novel improvements, and the farther out they are, as a general rule, the more set in their ways they get,” Dr Litwin said.
Marketplace competition also could explain why uptake of some technologies is greater in some places than others. For example, in areas served by multiple hospitals, all of those institutions might acquire an innovative machine to compete for patients.
- Wright JD, Tergas AI, Hou JY et al. Effect of regional hospital competition and hospital financial status on the use of robotic-assisted surgery. JAMA Surg. 2016;151:612-620. doi:10.1001/jamasurg.2015.5508
- Faiena I, Dombrovskiy VY, Modi PK, et al. Regional cost variations of robot-assisted radical prostatectomy compared with open radical prostatectomy. Clin Genitourin Cancer. 2015;13:447-4452. doi:10.1016/j.clgc.2015.05.004
- Preisser F, Nazzani S, Mazzone E, et al. Regional differences in total hospital charges between open and robotically assisted radical prostatectomy in the United States. World J Urol. 2019;37:1305-1313. doi:10.1007/s00345-018-2525-y
- Gaffney CD, Berg RWV, Cai P, et al. Increasing utilization of magnetic resonance imaging (MRI) prior to prostate biopsy in black and non-black men: An analysis of the SEER-Medicare cohort. Presented at: AUA Virtual Experience 2020, May 15. Poster MP42-18.
- Fam MM, Yabe JG, Macleod LC, et al. Increasing utilization of multiparametric magnetic resonance imaging in prostate cancer active surveillance. Urology. 2019;130:99-105. doi:10.1016/j.urology.2019.02.037
- Tooker GM, Truong H, Pinto PA, Siddiqui MM. National survey of patterns employing targeted MRI/US guided prostate biopsy in the diagnosis and staging of prostate cancer. Curr Urol. 2018;12:97-103. doi:10.1159/000489426
- Mahese SS, D’Angelo D, Kang J, et al. Trends in the use of stereotactic body radiotherapy for treatment of prostate cancer in the United States. JAMA Netw Open. 2020;3(2):e1920471. doi:10.1001/jamanetworkopen.2019.2071
- Baker BR, Basak R, Mohiuddin JJ, Chen RC. Use of stereotactic body radiotherapy for prostate cancer in the United States from 2004 through 2012. Cancer. 2016;122:2234-2241. doi:10.1002/cncr.30034
- Amini A, Raben D, Crawford ED, et al. Patient characterization and usage trends of proton beam therapy for localized prostate cancer in the United States: A study of the National Cancer Database. Urol Oncol. 2017;35:438-446. doi:10.1001/jamanetworkopen.2019.20471
- Oberlin DT, Flum AS, Lai JD, Meeks JJ. The effect of minimally invasive prostatectomy on practice patterns of American urologists. Urol Oncol. 2016;34:255.e1-255.e5. doi.org/10.1016/j.urolonc.2016.01.008
- Parsons JK, Messer K, Palazzi K, et al. Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. JAMA Surg. 2014;149:845-851. doi:10.1011/jamasurg.2014.31