SOURCE: American Society for Radiation Oncology

American Society for Radiation Oncology

September 16, 2013 09:00 ET

Renowned Urologist Dr. Patrick Walsh and Esteemed Radiation Oncologist Dr. Theodore DeWeese Denounce Self-Referral, Urge Passage of PIMA by Congress

FAIRFAX, VA--(Marketwired - September 16, 2013) - Nationally recognized urologist Patrick C. Walsh, MD, and leading radiation oncologist Theodore L. DeWeese, MD, both of Johns Hopkins University, join ASTRO today in denouncing the practice of physician self-referral for prostate cancer treatment and to clarify that the debate is not a turf war. The Government Accountability Office (GAO) issued a strikingly detailed report on August 1, 2013, specifically about self-referral for prostate cancer treatment, and ASTRO continues to push for swift Congressional passage of the Promoting Integrity in Medicare Act (PIMA).

Together, Drs. Walsh and DeWeese state:

"As a urologist and a radiation oncologist, we collaborate every day to provide high quality prostate cancer care to our patients. Today, we are proud to continue our work together on behalf of patients by pressing for an end to the wasteful overtreatment of prostate cancer resulting from the physician self-referral law's loophole for radiation therapy services.

Urology-ownership of radiation therapy presents a clear conflict of interest, often with a for-profit motive, that risks overuse of intensity modulated radiation therapy (IMRT). This activity is an affront to the vast majority of urologists and radiation oncologists who partner every day to provide well-coordinated care in community practices and hospitals without self-referral's additional financial incentives. 

Urologists and radiation oncologists have a shared interest in working side-by-side in the best interests of our patients, which should always supersede financial interests. For our patients and our own ethics, we disavow self-referral abuse, and we ask our urology and radiation oncology colleagues to join us to end it.

We agree with Senator Max Baucus and the recent GAO report that now is the time for Congress to take action to protect patients by closing the self-referral loophole and we strongly support passage of the Promoting Integrity in Medicare Act immediately."

On August 1, 2013, the GAO issued the comprehensive report -- "Medicare: Higher Use of Costly Prostate Cancer Treatment by Providers Who Self-Refer Warrants Scrutiny." Requested by bipartisan leaders in Congress, the report reviewed limited specialty [urology] groups' use of IMRT, an effective form of advanced radiation therapy, for prostate cancer treatment. The report found that from 2006-2010:

  • IMRT utilization among self-referring groups increased by 456 percent. Overall increases in IMRT utilization rates and spending were due entirely to services performed by limited-specialty groups. IMRT utilization among non-self-referrers decreased by 5 percent.
  • The number of IMRT services performed by limited specialty [urology] groups increased by 609 percent, while true multispecialty groups' IMRT use decreased 3.8 percent.
  • IMRT spending by self-referral groups increased by approximately $138 million, compared to a $91 million decrease in the non-self-referral group.
  • Increases in IMRT utilization among self-referring practices could not be attributed to patient preferences, age, geographic location or patient's health status. Financial incentives were likely a major factor in increased referrals for IMRT among the self-referring practices. The financial incentives for self-referral groups led to patients not receiving other appropriate and less expensive treatments, including brachytherapy, prostatectomy and active surveillance.
  • Self-referring centers referred more than 52 percent of men over the age of 75 for IMRT at self-referring centers. For these men, guidelines recommend active surveillance of their disease and the avoidance of aggressive treatment such as IMRT.

The GAO report concluded, "… the higher use of IMRT by self-referring providers results in higher costs for Medicare and beneficiaries. To the extent that treatment decisions are driven by providers' financial interest and not by patient preference, these increased costs are difficult to justify."

Earlier on August 1, U.S. Representative Jackie Speier (D-Calif.) introduced PIMA, HR 2914, cosponsored by Ways and Means Health Subcommittee Ranking Member Rep. Jim McDermott (D-Wash.) and Dina Titus (D-Nev.). PIMA would restore the original intent of the self-referral law by prohibiting self-referral for four complex services -- advanced imaging, anatomic pathology, radiation therapy and physical therapy, which are not typically performed at the time of the patient's initial office visit. The bill also enhances enforcement of the self-referral law by increasing penalties for improper referrals and creating new compliance review procedures involving Medicare and the HHS Office of Inspector General. Finally, the bill clarifies that physician groups participating in Accountable Care Organizations in the Medicare Shared Savings Program can continue to provide integrated services and maintains access to care for rural beneficiaries.

Dr. Walsh is the University Distinguished Professor of Urology and former director of The James Buchanan Brady Urological Institute at Johns Hopkins Medical Institutions. He is most known for his pioneering work in the development of "the anatomic approach to radical prostatectomy," which involves nerve-sparing techniques that reduce the probability of impotence and incontinence. Dr. Walsh is on the editorial board of the New England Journal of Medicine and was editor-in-chief for 25 years of Campbell's Textbook of Urology, which has been renamed Campbell Walsh in his honor. He has served as the president of both the American Association of Genitourinary Surgeons and the Clinical Society of Genitourinary Surgeons, and is the co-author of the best-selling book for patients, "The Prostate: A Guide for Men and the Women Who Love Them," and the author of, "Dr. Patrick Walsh's Guide to Surviving Prostate Cancer." 

Dr. DeWeese is the chairman of the Department of Radiation Oncology and Molecular Radiation Science and a professor in the Department of Oncology and Urology at the Johns Hopkins University School of Medicine, specializing in malignancies of the genitourinary system. His research focuses on the DNA-damage response of cancer cells (primarily prostate cancer) to ionizing radiation including repair, cell cycle perturbations and growth factor regulation. In addition, together with his colleagues, Dr. DeWeese is investigating the interaction of cytotoxic and differentiating drugs with radiation in human prostate cancer cells in hopes of identifying novel drug-radiation combination therapies.


ASTRO is the premier radiation oncology society in the world, with more than 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals that specialize in treating patients with radiation therapies. As the leading organization in radiation oncology, the Society is dedicated to improving patient care through professional education and training, support for clinical practice and health policy standards, advancement of science and research, and advocacy. ASTRO publishes two medical journals, International Journal of Radiation Oncology • Biology • Physics ( and Practical Radiation Oncology (; developed and maintains an extensive patient website,; and created the Radiation Oncology Institute (, a non-profit foundation to support research and education efforts around the world that enhance and confirm the critical role of radiation therapy in improving cancer treatment. To learn more about ASTRO, visit

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