News | October 24, 2013

Urologists Denounce New England Journal of Medicine Article Regarding Prostate Cancer Treatment

October 24, 2014 — Large Urology Group Practice Association (LUGPA), an organization advocating for integrated and coordinated urological care, says it has reviewed the article "Urologists' Use of Intensity-Modulated Radiation Therapy for Prostate Cancer" (Mitchell, JM, New England Journal of Medicine 369:17, Oct. 24, 2013) and found it to be methodologically flawed and factually inaccurate and, as such, did not contribute to the useful interchange of ideas needed to improve healthcare or increase value.

"The Mitchell study was commissioned and funded by the American Society for Radiation Oncology (ASTRO) in an attempt to persuade lawmakers to legislate a monopoly for its members in the use of radiation therapy to treat prostate cancer — an economically-driven agenda that has been rejected by Congress, MedPAC and the GAO," said Deepak Kapoor, president of LUGPA, and chairman and CEO of Integrated Medical Professionals PLLC. "Instead of furthering our understanding of the complicated health policy issues around prostate cancer care, Dr. Mitchell's work appears to be specifically designed to produce talking points for the sponsor's political agenda, which is primarily to restore their virtual monopoly on the provision of pathology laboratory services."

The data from the study by Jean Mitchell, Ph.D., economics professor at Georgetown University, stated that less than one-third of newly diagnosed prostate cancer patients who sought treatment from an integrated urology group received intensity-modulated radiation therapy (IMRT). This figure is in line with data from academic literature that predates the development of integrated groups.[1],[2] The study did not match its control group for practice size, patient demographics or severity of disease. According to Kapoor, its selection bias is evidenced by its own bizarre results. 

For example, the group says there has been a clear national trend toward less-invasive IMRT and away from brachytherapy seen nationally across all sites of service.[3][4] Paradoxically, over the six-year study period, the use of IMRT and brachytherapy remained flat in Mitchell's control group. The fact that integrated groups' rates of active surveillance and surgery held constant further illustrates that ownership of IMRT did not affect these groups' clinical decision-making. 

"Her own data confirms that urologists with ownership of radiation oncology use the technology appropriately and responsibly,” said Kapoor. “That should be the title of Mitchell's study.”

According to Kapoor, the ASTRO study serves only one purpose, to undermine competition in the marketplace, adding that utilizing such data that demonizes groups practicing evidence-based medicine in an attempt to manipulate market share by legislative fiat is both inappropriate and offensive. Legislative changes based on such data will drive up costs as many patients will be forced to seek care in the more expensive hospital setting, and harm patient access to specialized, integrated care.

Opinions expressed in this article are those of Kapoor and David Penson, M.D., professor of urologic surgery at Vanderbilt University and director of Vanderbilt Center for Surgical Quality and Outcomes Research.


[1] Nguyen PL, Gu X, Lipsitz SR, et al.  Cost Implications of the Rapid Adoption of Newer Technologies for Treating Prostate Cancer. J Clin Onc. 2010; Mar; 3: 1217 

[2] Jang TL, Bekelman JE, Liu Y, et al. Physician visits prior to treatment for clinically localized prostate cancer. Arch Intern Med. 2010;170(5):440-450. 

[3] Kapoor DA, Zimberg SH, Ohrin LM, et al. Utilization trends in prostate cancer therapy. J Urol. 2011 Sep;186(3):860-4. 

[4] Mahmood U, Pugh T, Frank S et al.  Declining use of brachytherapy for the treatment of prostate cancer.  Brachytherapy, in press.  Accessed at:

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