In US, 'Disconnect' in Prostate Cancer Surveillance

Nick Mulcahy

July 02, 2014

For prostate cancer specialists, beliefs about active surveillance (AS) and their actions are 2 very different things, according to the findings of a new survey.

The survey of 356 urologists and 361 radiation oncologists in the United States and was published in the July issue of Medical Care.

Most survey respondents (72%) said they agree that AS is an effective alternative to definitive treatment for men with low-risk prostate cancer.

However, when asked about a hypothetical 60-year-old man with low-risk prostate cancer, only 22% of the responding physicians recommended AS.

Instead, about 80% hypothetically recommended either surgery (radical prostatectomy) or some form of radiation therapy.

There is an "apparent disconnect" between clinicians' perceptions of the effectiveness of AS and their recommendations in the clinic, write the researchers, led by Simon Kim, MD, MPH, a urologist at the Yale School of Medicine in New Haven, Connecticut.

On the research team was radiation oncologist Paul Nguyen, MD, from Harvard Medical School in Boston.

"Multiple factors contribute to the disconnect," Dr. Kim told Medscape Medical News. These include the belief held by many specialists that primary treatments are most effective and the fact that, because AS is still considered "new," there is a "lag effect" in acceptance in community practice, he explained.

Radiation oncologists are the biggest laggards, the survey found. In comparison, urologists seem much more up to date.

For instance, urologists were significantly more likely than radiation oncologists to agree that AS is effective (75.5% vs 65.7%; < .001), and to report "comfort" in recommending it to low-risk prostate cancer patients (75.8% vs 61.7%; < .001).

Also, more radiation oncologists than urologists stated that their patients were "not interested" in AS (82.3% vs 59.1%; < .001).

"ASTRO is very worried about" the sluggish uptake of AS among radiation oncologists, said Anthony Zietman, MD, from the Massachusetts General Hospital and Harvard Medical School in Boston. He is the former president of American Society for Radiation Oncology (ASTRO), and was not involved in the survey.

"We believe our specialists need to change with the times," Dr. Zietman told Medscape Medical News in an interview.

In fact, radiation oncologists were less likely than urologists to have more than 10% of their patients managed with AS (24% vs 40%; < .001).

But the use of AS in patients with low-risk prostate cancer is not "particularly impressive" for either specialty. "There should be far more active surveillance than there is," Dr. Zietman said.

ASTRO is attempting to "right the ship," he explained. As part of its participation in the Choosing Wisely medical reform campaign, the organization has called for radiation oncologists to discuss AS with all men who have low-risk prostate cancer before initiating any radiotherapy.

Why are there such differences between radiation oncologists and urologists?

It is partially because radiation oncologists "not being incentivized financially," said Dr. Zietman.

"Patients are referred to radiation oncologists for treatment," he noted. "It's the end of line." If there is no treatment, there is no income.

In contrast, urologists are both treaters and managers. They suffer "less of a financial loss" if a patient chooses active surveillance, Dr. Zietman explained.

Multidisciplinary clinics featuring a radiation oncologist, a urologist, and a medical oncologist are a potential answer to the low rates of AS in the United States. The respective specialties "keep each other honest" in such a setting, he said. Such an approach is mandated in the United Kingdom and is employed in some American academic centers, such as the Massachusetts General Hospital.

Survey Design

The random sample of radiation oncologists and urologists came from the American Medical Association database. Dr. Kim and colleagues mailed the survey and a "token cash incentive" to 1366 physicians.

Respondents were asked to report the percentage of patients in their clinical practice being treated with AS (<5%, 5%–10%, 11%–15%, or >15%).

To assess "possible barriers in clinical practice" to AS, the survey used 2 clinical cases.

The first case featured a healthy 65-year-old patient diagnosed with low-risk prostate cancer on the basis of the following clinical features: a prostate-specific antigen level of 4 to 10 ng/mL, T1c disease, and a Gleason score of 6.

Respondents were asked whether AS would be an effective management strategy for this patient and whether they would feel comfortable routinely recommending AS.

The second case featured a healthy 60-year-old man diagnosed with localized prostate cancer with normal functional outcomes and a life expectancy of more than 10 years.

Respondents were asked which strategy they would recommend: AS, brachytherapy, external-beam radiation therapy, radical prostatectomy, or primary androgen deprivation.

In addition, the survey assessed whether the national rates of AS, brachytherapy, external-beam radiation therapy, and radical prostatectomy were being "overused," "used at the right rate," or "underused" in United States.

Perhaps not surprisingly, a higher proportion of radiation oncologists than urologists believe that radical prostatectomy is overused in the United States (70.3% vs 45.6%; < .001).

However, a higher proportion of urologists than radiation oncologists believe that brachytherapy (37.1% vs 17.8%; < 0.001) and external-beam radiation therapy (48.2% vs 32.4%; < 0.001) are overused nationally.

Like many academic experts, Dr. Kim and colleagues recommend that clinicians employ decision aids to improve patient knowledge about prostate cancer and related treatments.

Their hope is that shared decision-making will result in more judicious use of AS as an initial treatment in low-risk prostate cancer.

The study was supported by the Robert Derzon Award from the Medical Decision Foundations.

Med Care. 2014;52:579-585. Abstract


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