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MEDCAC Meeting 4/21/2010 - Radiation Therapy for Localized Prostate Cancer

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The Centers for Medicare and Medicaid Services (CMS) has called this MEDCAC to consider the evidence on the impact of radiotherapy for the treatment of localized prostate cancer on health outcomes.  CMS understands that there are other treatment options available for the treatment of localized prostate cancer, such as surgical interventions, cryoablation, ultrasound, etc.; however, a review of all available treatment options would be too wide in scope to accomplish at a single MEDCAC meeting.  Therefore, the scope of this MEDCAC is limited to radiotherapy for the treatment of localized prostate cancer with comparisons to watchful waiting.

With the advent of the prostate-specific antigen (PSA) test in the 1990s, the lifetime risk of being diagnosed with prostate cancer in the United States has nearly doubled to twenty percent.  However, the risk of dying of prostate cancer remains at approximately three percent.  Once prostate cancer has been diagnosed, the decision on the best course of treatment can be complex.  Numerous factors can influence the decision on how to proceed, including that some prostate cancers grow so slowly they would likely never cause significant problems during a patient’s lifetime.  The adverse effects of the available interventions and how they affect quality of life must also be considered.

As with any item or service, CMS asks whether or not it improves health outcomes, i.e., its overall benefits and harms for patients.  We ask the panel to address this question as it pertains to radiotherapy for the treatment of localized prostate cancer.  The outcomes of greatest interest for CMS include mortality and morbidity. Mortality may be measured by adjusted rates or survival time from diagnosis. Survival time from diagnosis may be influenced by lead and length time bias, which may be of particular relevance for slowly progressing conditions such as prostate cancer. Morbidity includes functional outcomes such as urinary incontinence, fecal incontinence, sexual dysfunction and adverse events from treatment such as rectal fistula, radiation burns and infections.

CMS looks forward to the Panel’s careful consideration of the evidence and its evidence based conclusions surrounding this topic.  The following voting and discussion questions identify for the Panel the issues of most interest to CMS regarding this complex topic.

November 13, 2009

Announced meeting.

March 2, 2010

Posted Federal Register notice announcing meeting.

March 8, 2010

Posted questions to panel.

April 16, 2010

April 20, 2010

April 26, 2010

Posted presentations and scoresheet [PDF, 134KB] from meeting.

October 20, 2010

Posted transcript [PDF, 378KB] and minutes [PDF, 114KB] from meeting.
Federal Register Notice
Medicare Evidence Development & Coverage Advisory Committee
April 21, 2010
7:30 AM – 4:30 PM
CMS Auditorium

Clifford Goodman, PhD, Chair
Saty Satya-Murti, MD, Vice Chair
Marcel Salive, MD, Director, Division of Medical & Surgical Services, CAG
Maria Ellis, Executive Secretary

7:30 – 8:00 AM    


8:00 – 8:15 AM  

Opening Remarks—Maria Ellis/Marcel Salive, MD/Clifford Goodman, PhD

8:15 - 8:25 AM

CMS Presentation of Voting Questions – Deirdre O’Connor

8:25 – 9:10 AM

TA Presentation:  Thomas Dvorak, MD, Clinical Instructor, Department of Radiation Oncology; Stanley Ip, MD, Assistant Director, Evidence-based Practice Center; Raveendhara R. Bannuru, MD, Senior Research Associate, Evidence-based Practice Center, Tufts Medical Center, Boston, MA

9:10 – 10:00 AM 

Scheduled Public Comments – Part 1
(Refer to Speaker List)

10:00 – 10:15 AM


10:15 – 11:00 AM

Scheduled Public Comments – Part 2
(Referto Speaker List)

Public attendees, who have contacted the executive secretary prior to the meeting, will address the panel and present information relevant to the agenda. Speakers are asked to state whether or not they have any financial involvement with manufacturers of any products being discussed or with their competitors and who funded their travel to this meeting.

11:00 – 11:15 AM

Open Public Comments

Public Attendees who wish to address the panel will be given that opportunity

11:15 – 12:00 PM

Questions to Presenters

12:00 – 1:00 PM

LUNCH (on your own)

1:00 – 2:00 PM

Initial Open Panel Discussion: Dr. Goodman

2:00 – 3:00 PM

Formal Remarks and Voting Questions

The Chairperson will ask each panel member to state his or her position on the voting questions

3:00 – 4:00 PM  

Final Open Panel Discussion: Dr. Goodman

4:00 – 4:30 PM 

Closing Remarks/Adjournment: Dr. Salive & Dr. Goodman

Download meeting minutes [PDF, 114KB].

For the following voting questions, use the following scale identifying level of confidence - with 1 being the lowest or no confidence and 5 representing a high level of confidence.

1      —      2      —      3      —      4     —      5
Low                   Intermediate                      High
Confidence                   Confidence                       Confidence

For the purpose of questions 1 thru 4, the outcomes of interest are defined as:

  1. Mortality – survival and death rate
  2. Functional outcomes – erectile dysfunction, urinary incontinence, fecal incontinence
  3. Adverse events – rectal fistula, radiation burns, infection.
  1. How confident are you that there is adequate evidence to determine if radiation therapy for the treatment of localized prostate cancer affects each of the following health outcomes?

    1. Mortality
    2. Functional outcomes
    3. Adverse events
  1. How confident are you that the evidence is adequate to conclude that the use of external beam radiation therapy improves each of the health outcomes listed below as compared to a therapeutic strategy of watchful waiting?

    1. Mortality
    2. Functional outcomes
    3. Adverse events
  1. How confident are you that the evidence is adequate to conclude that the use of brachytherapy improves each of the health outcomes listed below as compared to a therapeutic strategy of watchful waiting?

    1. Mortality
    2. Functional outcomes
    3. Adverse events
  1. How confident are you that the evidence is adequate to conclude that the use of each of the modalities identified below improves each of the health outcomes listed, over the identified comparator?

    1. Stereotactic body radiation therapy (SBRT, including CyberKnife therapy) compared to classically fractionated external beam radiation therapy (EBRT, including 3D-conformal radiation therapy, intensity modulated radiation therapy, and particle therapy)
      1. Mortality
      2. Functional outcomes
      3. Adverse events

    2. SBRT compared to high dose rate brachytherapy (HDR).
      1. Mortality
      2. Functional outcomes
      3. Adverse events
    3. SBRT compared to low dose rate brachytherapy (LDR).
      1. Mortality
      2. Functional outcomes
      3. Adverse events
  1. How confident are you that these conclusions are generalizable to:

    1. the Medicare patient population?
    2. community based settings?

Discussion Questions

  1. What type of additional evidence on the impact of radiotherapy on prostate cancer outcomes is needed to improve decision making in the approach to treating localized prostate cancer?

  2. How can the medical research and provider community address the evidentiary gaps that may contribute to health disparities that exist in the diagnosis, treatment and outcomes for localized prostate cancer?

Download scoresheet [PDF, 134KB].

Clifford Goodman, PhD Chair
Senior Vice President
The Lewin Group

Saty Satya-Murti, MD, FAAN Vice Chair
Health Policy Consultant

Charles S. Carignan, MD
Executive Vice President
Chief Medical Officer
Novasys Medical, Inc.

Roger Dmochowski, MD
Department of Urology
Vanderbilt University

Josef E. Fischer, MD
Harvard Medical School
William V. McDermott Professor of Surgery
Renaissance Building

James M. Hevezi, PhD, FACR/FAAPM
ACR Board of Chancellors
Chair, Commission on Medical Physics
Director of Medical Physics
CyberKnife Center of Miami

Jeffrey G. Jarvik, MD, MPH
Radiology & Neurosurgery
Department of Radiology
University of Washington

Roger D. Klein, MD, JD
Medical Director
Molecular Oncology
BloodCentr of Wisconsin

Barbara McNeil, MD, PhD
Department of Health Care Policy
Harvard Medical School

Curtis A. Mock, MD, MBA
National Medical Director
VP Medicare Advantage Ovations

Louis Potters, MD, FACR
Department of Radiation Medicine
North Shore Long Island Jewish Health

David J. Samson, MS
Blue Cross and Blue Shield Association

Sanford J. Schwartz, MD
Professor of Medicine, Health Management & Economics
University of Pennsylvania

Robert L. Steinbrook, MD
Adjunct Associate Professor of Medicine and Community and Family Medicine
Dartmouth Medical School

Craig Umscheid, MD, MSCE
University of Pennsylvania
School of Medicine

Industry Representative

G. Gregory Raab, PhD
Health Policy Consultant
Raab Associates

CMS Liaison

Marcel Salive, MD
Division of Medical & Surgical Services
Coverage and Analysis Group

Executive Secretary

Maria A. Ellis

Medicare Evidence Development & Coverage Advisory Committee
April 21, 2010

  • Peter Grimm, DO, Executive Director, Prostate Cancer Treatment Center Seattle
  • Jonathan Briers, MD, Vice President, Medical Affairs, Nucletron
  • Howard Sandler, MD, MS, Ronald H. Bloom, Chair in Cancer Therapeutics, Professor and Chair, Department of Radiology Oncology, Cedars-Sinai Medical Center
  • Luther W. Brady, MD, Distinguish University Professor, Hylda Cohn/American Cancer Society, Professor of Clinical Oncology, Professor Department of Radiation Oncology, Drexel University College of Medicine
  • Albert Blumberg, MD, Representing: American College of Radiology (ACR)
  • Sean P. Collins, MD, PhD, Department of Radiation Medicine, Georgetown University Hospital, Lombardi Comprehensive Cancer Center
  • Carl Olsson, MD, John K. Lattimer Professor and Chairman, Department of Urology at the College of Physicians and Surgeons of Columbia University and Chief of the Squier Urological Clinic of the Presbyterian Hospital in New York City Representing: American Urological Association
  • Andrew K. Lee, MD, MPH, Associate Professor, Radiation Oncology, MD Anderson Cancer Center
  • Gregory S. Merrick, MD, Schiffler Cancer Center and Wheeling Jesuit University, Wheeling, WV
  • Chrissie Kotwica, RN, BSN, CyberKnife Coalition Member, CyberKnife Centers of Miami and Palm Beach
  • Alan Katz, MD, Associate Professor of Radiation Oncology, Medical Directory, Department of Radiation Oncology, University of Rochester Medical Center
  • Anthony Zietman, MD, Representing: American Society for Radiation Oncology (ASTRO)