Dear AUA Member, The AUA is aware of and has issued the following response to an article published today

by the New England Journal of Medicine (NEJM) entitled Urologists Use of Intensity-Modulated Radiation Therapy for Prostate Cancer. The article, by Dr. Jean Mitchell, will appear in the October 24 edition of the NEJM. The following statement has been released by the AUA: The American Urological Association (AUA) is committed to ensuring the delivery of appropriate, highquality healthcare to men with prostate cancer and welcomes the opportunity to discuss these issues in a constructive manner. Unfortunately, given its inherent biases and flawed methodologies, Dr. Mitchells article does not contribute to the discourse. Specifically, there are serious concerns about the authors selection of control groups that may not be representative of general practice trends. Prior studies using the SEER database (the data source considered most reflective of the United States as it includes roughly 25 percent of the U.S. population affected with cancer) have shown significant declines in the use of brachytherapy in the United States during the same time period, yet Dr. Mitchells control groups fail to show any decline in brachytherapy use[i]. As the methods used to select the control groups are poorly described, one cannot help but wonder whether Dr. Mitchell chose the control groups to arrive at results that were acceptable to the studys sponsors. Limitations of the current study aside, the AUA supports initiatives that benefit patients by providing coordinated, continuous care and management of urologic disease, including IMRT. Earlier this year, the AUA Board of Directors adopted a set of guiding principles for in-office ancillary services to help guide its members. We believe that provision of ancillary services, such as IMRT, should be transparent and in the patients best interest, with all treatment advice or referrals based on objective, medically acceptable and supported recommendations. Patients should be reassured that their urologic care will not be disrupted or penalized if they seek an alternate physician supplier or provider of IMRT. In its June 2011 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended against limiting the Stark law exception for ancillary services, citing potential unintended consequences, such as inhibiting the development of organizations that integrate and coordinate care within a physician practice. The General Accountability Office (GAO) recently issued a series of reports on self-referral and flatly rejected the recommendation to limit the Stark exception. As a leading advocate for the specialty of urology, the AUA is committed to advancing research that will improve quality of care for patients with urologic disease. The AUA is developing a quality registry, AQUA, that is designed to provide data to help identify trends in the diagnosis and treatment of prostate cancer and eventual outcomes related to treatment options. The registry will be launched in 2014.

[i] Mahmood, U.; Pugh, T.; Frank, S.; et al. Declining use of brachytherapy for the treatment of prostate cancer. Brachytherapy. In press (http://dx.doi.org/10.1016/j.brachy.2013.08.005).