Study: There Is a Free Lunch (for Prostate Cancer Docs)

Nick Mulcahy

August 17, 2017

The maxim, "There's no such thing as a free lunch," may not apply to some clinicians who prescribe two hormonal therapies for advanced prostate cancer and who take gift payments from industry, according to new study results.

There was a lack of a relationship between physician payments from drug manufacturers and Medicare claims for abiraterone (Zytiga, Johnson & Johnson) and enzalutamide (Xtandi, Astellas), report the study authors, led by Jathin Bandari, MD, a urologist at the University of Pittsburgh in Pennsylvania.

"No difference in prescription count was found to exist between prescribers who received industry payments and those who did not," the authors write in their study, published online July 27 in Cancer.

"Generally speaking, physicians do not believe payments have a major influence on prescribing behavior. Our study supports this hypothesis at the median level," Dr Bandari told Medscape Medical News. More controversy exists at "extremely high payment levels," and the new results indicate that, at those levels, payments may have influence, he added.

Generally speaking, physicians do not believe payments have a major influence on prescribing behavior. Dr Jathin Bandari

The results run counter to multiple other studies that have indicated that payments ― even small ones ― can influence prescribing behavior.

The study authors observe that abiraterone and enzalutamide are the two most widely prescribed drugs for metastatic castrate-resistant prostate cancer, with $2.2 billion and $1.9 billion in sales, respectively, reported in 2015.

But they are also pretty much the only choices for men and their clinicians if disease progresses following androgen deprivation therapy (ie, castration). That may influence the new results, say the authors. Prescribers may be "relatively insensitive" to industry payments because the two drugs will be prescribed "in any case."

In the new study, the definition of industry payments included paid meals.

Most Docs Who Take Payment Don't Prescribe

In the new study, the researchers reviewed information in two Medicare databases, including one that tracks industry payments to physicians, for the year 2014.

Notably, the vast majority of 13,000-plus urologists and oncologists who received payment from either Johnson & Johnson or Astellas Pharmaceuticals that was earmarked for abiraterone or enzalutamide never prescribed the drugs during the study period. Only 11% of the physicians who received payments related to abiraterone went on to prescribe the drug. And only 4% of the physicians who received payments related to enzalutamide went on to prescribe it.

When the investigators studied the physicians who did prescribe the drugs, they did not find that payments led to an increase in prescribing.

Among the 1812 abiraterone prescribers, 34% received payments, but there was no statistically significant difference between recipients and nonrecipients with regard to the total number of scripts (18 vs 18, P = .66).

Among the enzalutamide prescribers, 41% received payments, but, again, there was no difference between recipients and nonrecipients with regard to the total number of scripts (15 vs 15.5, P = .66).

However, the amount of pay was influential in the case of one drug.

The researchers report that among enzalutamide prescribers, there was a statistically significant association between the amount of the industry payment and the prescription count.

The median industry payment amount significantly differed between prescribers and nonprescribers for enzalutamide ($59 vs $31; P <.01).

To evaluate payment effects on outliers, prescribers were stratified by quantile according to the total number of prescriptions.

The researchers found that a lot of money was needed to increase prescribing.

They reported that, for abiraterone, $10,000 was predicted to be necessary to increase the average number of prescriptions by one for the lowest two quantiles, and $2000 to $4000 was necessary for the last three quantiles.

Similarly, for enzalutamide, physicians within the first three quantiles would require up to $60,000 to increase the average number of prescriptions by one, whereas those in the last two quantiles would only require $1000.

Other Studies Found Influence

For prostate cancer, abiraterone and enzalutamide are practically the only available choices. This situation is very different from, for example, the prescribing of brand-name statins or beta blockers vs generics, in which many drugs are available and there is competition for attention and the writing of prescriptions, observe the authors. In cases in which there is competition, gift payments could tip the scales in favor of one agent over another, suggest the authors.

A 2016 study found that that is what happened. Receipt of industry-sponsored meals was associated with an increase in the rate of prescribing of brand-name statins, beta blockers, and other classes of drugs that were being promoted. The mean value of the meals in the study was only about $20 (JAMA Intern Med. 2016;176:1114-1122).

Whether during a meal or a "detailing" office visit, physician interactions with drug company representatives can influence subsequent prescribing, according to research.

Two months ago, investigators in the United States reported that from 2006 to 2012, among academic medical centers, policies that restricted pharmaceutical detailing were associated with modest but significant reductions in the prescribing of detailed drugs across six of eight major drug classes (JAMA. 2017;317:1785-1795).

No funding for the study has been reported. The authors have disclosed disclosed no relevant financial relationships.

Cancer. Published online July 27, 2017. Abstract

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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