Doctor characteristics may influence prostate cancer treatment
Whether a man’s low-risk prostate cancer gets treated with surveillance, surgery or another method may have more to do with his doctor than his health, according to a new study.
Urologists who had been practicing for more years and those who treated more advanced cases of the disease were less likely to use a wait-and-see approach to manage low-risk prostate cancer, researchers found.
“The physician a patient sees can influence their treatment fate,” said Dr. Karen Hoffman. “Physicians play an important role in whether or not men with low-risk prostate cancer are managed with observation or treatment.”
Hoffman is the study’s lead author from the University of Texas MD Anderson Cancer Center in Houston.
Almost 200,000 men are diagnosed with prostate cancer each year in the U.S. and about 30,000 die from it, according to the Centers for Disease Control and Prevention.
Hoffman and her colleagues write in JAMA Internal Medicine that non-aggressive, also known as low-risk, prostate cancer is not likely to lead to symptoms or affect how long men live.
Instead of treating men with surgery to remove their prostate, radiation or other methods, medical organizations have endorsed the use of active surveillance or observation to make sure a low-risk cancer is not growing or advancing.
That’s in part because treatment for prostate cancer can lead to complications like rectal bleeding, impotence and problems with bladder control.
Which treatments patients receive is thought to be dependent on several factors, including their age and the severity of their other health conditions.
It hasn’t been known whether doctor characteristics influence treatment decisions, however.
For the new study, the researchers analyzed data from 12,068 men ages 66 years and older who were diagnosed with low-risk prostate cancer by 2,145 urologists between 2006 and 2009.
Only about a fifth of the men were treated with active surveillance. The rest received up-front treatment, such as surgery or radiation.
The proportion of patients that each doctor put on active surveillance varied from less than five percent to about 64 percent.
The researchers found that doctor characteristics were twice as important as patient characteristics, such as age and other conditions, in predicting whether a patient would receive active surveillance or up-front treatment.
Doctors who treated more aggressive prostate cancers and those who had been practicing urology longer were more likely to use treatment other than active surveillance, the researchers found.
They suggest doctors who treat more advanced cancers may choose more aggressive treatment even for their low-risk patients because they have seen the damage prostate cancer can do if left untreated. It may also be that doctors are incentivized to use more aggressive treatment because it pays more.
“The rate of treatment of older men with low-risk disease is well documented to be extremely high,” said Dr. H. Ballentine Carter, professor of urology and oncology at Johns Hopkins Medicine in Baltimore.
“I think patients need to be aware,” said Carter, who was not involved with the new study. “They may never become aware before they undergo treatment. I think we need to do a better job of educating older individuals with low-risk disease.”
He said the question should not be which treatment men need but whether they need to be treated.
A second study published in the same journal found that another treatment for prostate cancer known as androgen-deprivation therapy did not improve survival for older men with low-risk disease after 15 years.
One option for reducing potentially unnecessary treatment is for the observation rates of doctors who treat prostate cancer to be made public so primary care doctors would know that information before they referred their patients.
Of course, Hoffman said doctors would also want to base their decision on other measures, such as complications after treatment and follow-up care, because active surveillance is not always the best treatment option.
“There is variation in physician use of active surveillance,” she said. “I think patients should ask their urologists and radiation oncologists if they are candidates for active surveillance.”
SOURCE: JAMA Internal Medicine, online July 14, 2014.
Physician Variation in Management of Low-Risk Prostate Cancer
Conclusions and Relevance Rates of management of low-risk prostate cancer with observation varied widely across urologists and radiation oncologists. Patients whose diagnosis was made by urologists who treated prostate cancer were more likely to receive up-front treatment and, when treated, more likely to receive a treatment that their urologist performed. Public reporting of physicians’ cancer management profiles would enable informed selection of physicians to diagnose and manage prostate cancer.
Karen E. Hoffman, MD, MHSc, MPH; Jiangong Niu, PhD; Yu Shen, PhD; Jing Jiang, PhD; John W. Davis, MD; Jeri Kim, MD; Deborah A. Kuban, MD; George H. Perkins, MD; Jay B. Shah, MD; Grace L. Smith, MD, PhD, MPH; Robert J. Volk, PhD; Thomas A. Buchholz, MD; Sharon H. Giordano, MD, MPH; Benjamin D. Smith, MD