Underutilization

why RIT is underutilized

So if RIT is potentially curative, why isn’t it flying off the shelves and into patients? Why have fewer than 10% of eligible patients actually gotten it since it was approved in 2002? The simple answer is that oncologists have no financial incentive to use it, but wait - don’t get mad at your doctor! Instead, understand why and you’ll be better equipped to find out of you qualify for RIT.

So here’s the story. The administration of any treatment or test with radioactive components, including RIT, requires special licensing, which few oncologists have or need. This means that oncologists refer patients to radiation oncologists or nuclear medicine physicians, who hold the special licensing, for administration of RIT, which is usually done in hospitals.

Referring patients to other specialists is not unusual in oncology. Oncologists routinely coordinate with other specialists when their patients need external beam radiation or surgery, so coordinating with others for the administration of RIT shouldn’t be different.

But it has historically been different, and still is, primarily for two reasons. The first is that when oncologists refer patients for external beam radiation or surgery, those procedures are usually the only options for specific conditions, or at least the best options as universally agreed by medical experts. For many types of lymphoma, especially the indolent types, there is no universally agreed-upon “only” treatment. In other words, there are usually choices for treatment – and for all of us, it’s great that we have options. It’s just that most frequently, our options include treatments that our doctors can prescribe and administer, and those treatments don’t include RIT.

And that leads to the second reason why RIT has been treated differently. Our current health care system allows oncologists to purchase drugs they can prescribe and administer – namely, chemotherapy drugs and Rituxan – at wholesale rates and “sell” them at amounts that are capped by a governmental agency (the Centers for Medicare and Medicaid Services, or CMS), and most private insurers follow suit. This system helps to support private practices, and it’s worth noting that profit margins have always been modest and they’re shrinking every year. It should also be noted that physicians at universities, because they’re salaried, do not benefit by prescribing one drug or treatment over the other.

Unfortunately for patients who could benefit from RIT, this system also means that most oncologists have no financial incentive to use it. An article in the Journal of Clinical Oncology states, "Despite the overwhelming body of evidence that has accumulated, however, RIT remains underused...related, at least partially, to logistic issues involved in transfer of care from the hematologist/oncologist to the nuclear medicine physician and concerns about inadequate reimbursement..."

Another article in the Journal of the National Cancer Institute (see full article at link on left) puts it this way: "RIT is far from ideal for the medical oncologists in private practice who make treatment decisions. To give Zevalin and Bexxar, doctors must refer patients to radiation oncologists or nuclear medicine specialists and then coordinate treatment. This involves more effort than simply giving chemotherapy drugs or rituximab in clinic - and it means less money...So RIT, viewed from the standpoint of the medical oncologist's convenience and financial compensation, has problems." My rebuttal is always the same: having lymphoma is inconvenient for us patients, too (understatement!).

A 2010 survey asking oncologists for their views of RIT confirmed that they are concerned about the adverse economic impact on their practices. (Full pdf file at left)

It’s important to remember that physicians neither created this system nor can they fix it, and I truly believe that they do their very best to work within it for the good of their patients, but the system does place doctors in the position of keeping up with the therapies that they can prescribe and administer rather than ones that they can’t – and there are plenty of those to keep up with, especially for oncologists who treat all kinds of cancers.

Another, more subtle influence, may also factor into treatment recommendations. Every one of us, including doctors, has certain predispositions. On its website, Patients Against Lymphoma, sums it up this way: “Even the best doctors can have conflicts of interest, biases or gaps in knowledge...Investigators may have an intellectual bias about an investigational therapy they are testing. A community doctor might have a bias in favor of what’s easier to administer. An HMO physician may prescribe what is least expensive. Another doctor might be influenced, unconsciously or not, by sales promotions from the drug industry.”

Putting all this into perspective, every day we buy goods and services from businesses which profit from our purchases. Most medical practices fall into this category. They are for-profit businesses – and thank goodness they are. Their profitability enables them to stay in business and treat us when we’re sick. But before deciding on a treatment plan, we simply need to be aware that the business of running a medical practice can potentially influence treatment recommendations. In the case of RIT, all too often the burden falls squarely on patients to find and talk with an oncologist who is experienced in treating patients with it, who knows the facts, and who neutrally presents the risks and benefits of all options, not just the ones he or she can administer.

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