Men who visit a radiation oncologist appear more likely to receive radiation therapy for prostate cancer, whereas men who consult with a urologist with or without a medical oncologist are treated more frequently with hormone therapy, watchful waiting or a radical prostatectomy, according to a report in the March 8 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
For most of the nearly 200,000 American men diagnosed with prostate cancer each year, the disease is localized (i.e., has not yet spread), according to background information in the article. Treatment options for these men include surgery to remove the prostate and surrounding tissue (radical prostatectomy), radiation treatment, hormone therapy (including primary androgen deprivation therapy) or watchful waiting (expectant management). "Selecting the appropriate treatment can be challenging, since no therapy has emerged as clearly superior," the authors write. "Patients rely on the clinical judgment, treatment philosophy and recommendations of counseling physicians to help them make informed decisions."
Clinicians' perceptions regarding optimal prostate cancer therapy appear to vary by specialty and geographic region. To assess whether these preferences were associated with treatment decisions, Thomas L. Jang, M.D., M.P.H., then of Memorial-Sloan Kettering Cancer Center, New York, and now of The Cancer Institute of New Jersey, New Brunswick, and colleagues identified 85,088 Medicare beneficiaries age 65 or older who were diagnosed with prostate cancer between 1994 and 2002.
Overall, 42,309 men (50 percent) were seen only by urologists, 37,540 (44 percent) by urologists and radiation oncologists, 2,329 (3 percent) by urologists and medical oncologists and 2,910 (3 percent) by all three specialists. Within nine months of diagnosis, 21 percent (18,201) had a radical prostatectomy, 42 percent (35,925) received radiation therapy, 17 percent (14,021) underwent primary androgen deprivation therapy and 20 percent (16,941) chose watchful waiting.
The type of treatment was strongly associated with the type of specialist consulted. Thirty-four percent of men who were seen exclusively by a urologist had a radical prostatectomy; it was the most frequent form of therapy in men 65 to 74 years who were seen only by urologists. In contrast, radiation therapy was the most common treatment for men of all ages who saw both radiation oncologists and urologists. Those seen by urologists, with or without medical oncologists, were more likely than those evaluated by urologists and radiation oncologists to receive primary androgen deprivation therapy or watchful waiting.
Visits to primary care physicians were infrequent between the time a man was diagnosed and when he started treatment; 22 percent of patients visited any primary care clinician during this timeframe, and 17 percent visited a primary care clinician with whom he had an established relationship. Regardless of age, co-occurring illnesses or specialist visits, men who saw primary care clinicians were more likely to be treated with watchful waiting.
"Our findings provide new insight into the relationship between physician visit patterns and receipt of therapy for localized prostate cancer," the authors write. "Prior physician surveys suggest that urologists and radiation oncologists might recommend their own treatment modality based on their stated preferences in response to hypothetical survey questions. The pattern of specialist visits and treatment that we observed suggests that these preferences may be affecting treatment decisions of Medicare patients."
"This finding and the known preferences of prostate cancer specialists for the treatment they themselves deliver underscores the need to ensure that all men are well informed and have access to balanced information prior to making this important treatment decision," they conclude.
- Thomas L. Jang; Justin E. Bekelman; Yihai Liu; Peter B. Bach; Ethan M. Basch; Elena B. Elkin; Michael J. Zelefsky; Peter T. Scardino; Colin B. Begg; Deborah Schrag. Physician Visits Prior to Treatment for Clinically Localized Prostate Cancer. Arch Intern Med, 2010; 170 (5): 440-450 [link]
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