The case for prostate brachytherapy in the Affordable Care Act era.

Few oncologic entities are more deserving of national scrutiny than low-risk prostate cancer. Prostate cancer is among the top 5 most costly cancers, with $11.9 billion spent annually in the United States (1). Recent publications have drawn attention to financially driven practices and questionable referral patterns (2, 3). The Congressional Budget Office estimates that half the increase in health care expenditures over the past decades has been driven by expanded capabilities associated with new technologies (4). Intensity modulated radiation therapy (IMRT) and proton therapy come to mind. IMRT now accounts for more than 80% of radiation therapy treatments (5). Brachytherapy, by contrast, has been steadily declining in the United States (6). Payors are taking notice. Blue Shield of California and Aetna have stopped covering proton therapy for prostate cancer. Government and privately administered health insurers cut costs by reimbursing IMRT at a fraction of the billable rate. Treating institutions respond by inflating rates to compensate for aggressive cuts.