COMMENTARY

Physician Approaches to Prostate Cancer Vary Widely

Gerald Chodak, MD

Disclosures

August 12, 2014

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Hello. I am Dr. Gerald Chodak, for Medscape. Today I want to talk about an article in JAMA Internal Medicine by Hoffman and coworkers,[1] who attempted to find out how likely it is that a man diagnosed with low-risk prostate cancer would be treated conservatively.

These authors conducted a retrospective review of people in the SEER program for men over age 65 years, totaling more than 12,000 patients treated by more than 140 urologists. They also looked at the relationship between seeing a radiation oncologist and the likelihood of receiving conservative therapy.

They found a wide variation in the likelihood of these men ending up with observation rather than some form of active treatment: from about 4.5% to 67% for those who saw a surgeon, and from 2% to about 45% for those who saw a radiation oncologist. In fact, men who saw both a urologist and a radiation oncologist were much more likely to receive active treatment. In all, 70% of men between age 66 and 70 years received active treatment, not observation; even for the men over age 80, 50% received active treatment and only 50% received observation. Thus, this study shows us the wide variation in practice across doctors and across specialties. The next question is, what do we do about that?

Study Limitations

There are limitations to the study that we need to acknowledge. For example, the study was retrospective, looking at records from 2006 to 2009. With the recent attention given to conservative therapy, practice may have changed significantly in the past 5 years, even for the doctors who were part of this survey.

Another problem is that we have no idea what men were told when they were presented with treatment options for a low-risk cancer in that age group. It is possible that some doctors did not discuss observation or were negative about it; or, doctors may have presented and discussed it, even encouraged it, but the patient and his partner may have been unwilling to accept that recommendation. It may be anxiety or family history that drives patients' decisions. Thus, there are factors that may be influencing this outcome that we cannot determine.

In addition, there may have been an overestimation of the men who were treated conservatively, because for men who end up undergoing radical prostatectomy in the SEER database, the final pathology grade is the one that is recorded. This means that men who had low-risk disease on biopsy may have ended up with intermediate-risk disease at the time of radical prostatectomy, which would exclude them from the study.

What Can We Do About This?

A variety of recommendations have been suggested to reduce this wide variation in practice. One suggestion is to publish a database that informs patients about doctors' performance. If you see a given doctor, what is the likelihood that you are going to get treatment A, treatment B, or treatment C? In that way, patients would have an awareness of what to expect when they are informed by or receive advice from their doctors.

Another suggestion, which I have supported in the past, is to develop a standardized presentation not only about observation but about all of the other treatments. Doctors, of course, can add information, but standardized information would ensure that at least the available factual information is presented to patients. For example, one wonders how many of the men in the past 5 years have been informed about the results of the PIVOT trial[2] or the Scandinavian randomized trial[3] when discussing treatment, because those studies found no survival benefit to radical prostatectomy for men over 65.

In the end, we have a changing paradigm where an increasing number of doctors recognize that many men are being overtreated for prostate cancer, and it seems that in older men, who are less likely to benefit from treatment anyway, there is a great opportunity to increase their acceptance of observation with active surveillance.

I look forward to your comments. Thank you.

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