A poster to be presented at the upcoming ASCO annual meeting gives us some insights into the actual behaviors of physicians and their patients regarding the use of active surveillance today in the “real world” of clinical practice (as opposed to clinical trials and case series at academic medical centers).
The abstract of the poster to be presented at ASCO by Kim et al. is based on data from a survey sent to > 1,400 urologists and radiation oncologists between late 2011 and early 2012. These physicians were asked to provide information about their views on active surveillance as a management strategy for men with low-risk or very low-risk prostate cancer defined as PSA < 10 ng/ml, clinical stage T1c, Gleason 6 cancer in only 1/12 biopsy cores. (Note that this is a lower definition of “low risk” than that recommended by the National Comprehensive Cancer Network.)
Here are the results of the survey as presented by Kim et al.:
- The survey was sent (by mail ) to a population-based sample of 1,439 US-based urologists and radiation oncologists.
- 643/1,439 physicians (44.7 percent) completed and returned the survey, including
- 321 radiation oncologists
- 322 urologists
- 71 percent of the respondents stated that active surveillance is an effective management strategy for low-risk prostate cancer.
- 67 percent of the respondents stated that they were comfortable routinely recommending active surveillance.
- Urologists were more likely to agree that active surveillance is effective than radiation oncologists (77 vs. 67 percent; p = 0.005).
- Urologists were more comfortable recommending active surveillance than radiation oncologists (74 vs. 61 percent; p = 0.001).
- Most physicians actually recommended either radical prostatectomy (47 percent) or radiation therapy (32 percent) for treatment of low-risk disease.
- Only 21 percent of physicians actually recommended active surveillance.
- Radiation oncologists were more likely to recommend radiation therapy (OR = 10.97; p < 0.001).
- Urologists were more likely to recommend surgery (OR = 4.69; p < 0.001) and active surveillance (OR = 2.18; p = 0.001).
The results of this survey appear to confirm a widespread perception that, despite a theoretical appreciation of the value of active surveillance, neither the urology community nor the radiation oncology community, as yet, are fully committed to practicing what is recommended in clinical guidelines and justified by the available clinical data.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Treatment, Uncategorized Tagged: | active surveillance, low risk, Management
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I was quite surprised to see that 71 per cent said that active surveillance is an effective management strategy for low-risk prostate cancer, and that 67 percent of the respondents stated that they were comfortable routinely recommending active surveillance.
That seemed pretty positive until (and I realise I am slow on the uptake at times) that those percentages were only applicable to the 44 per cent of the doctors who responded to the survey.
Assuming that the majority who did not responsd would not agree with these two statements, the 71/67 percentages drop to about 31/30 per cent and the 21 percent who said they actually recommended AS drops back to less than 10%.
That made more sense.
Terry:
Your assumption may make you feel more comfortable, but it is certainly not a justifiable assumption. It is actually rather surprising that as many as 45% of the target audience for the survey responded at all.
I believe that Terry is right on the mark with his assumption. I am involved in the national NCI active surveillance study at M. D. Anderson in Houston, Texas. My urologist there tells me, and argues with me, to have my prostate removed. We have a long way to go to educate our doctors so that they can truly recommend active surveillance.
Dear Ray:
No one is disagreeing that there is a long way to go before all urologists and radiation oncologists are actually willing to apply active surveillance in a consistent and reasonable manner. However, Terry’s calculation that only 10% of urologists actually recommend active surveillance can’t be justified by simply assuming that all of the doctors who didn’t respond to the survey discussed above don’t recommend active surveillance. That is like assuming that all of the drivers who didn’t respond to a survey on their driving habits are bad drivers. They may just not have answered the survey!
The survey is interesting enough in itself in that there is a very large discrepancy between the apparent willingness of the physicians who did answer the survey to consider recommending active surveillance (at 65 to 70%) and their actual practice of such recommendation (at only 21%). If you think something is reasonable, why wouldn’t you do it? Is this about fear of legal consequences (in America)?
By recommending active surveillance a doctor deprives himself of a large fee for doing surgery or radiation. A big conflict of interest. I am 81 and many times in my life I have had unnecessary treatment. The last being an extremely expensive hormone injection (Zoladex) given by my oncologist after radiation therapy. It made me so sick and ill life was not worth living. The oncologist charged me four times the pharmacy price. My urologist claims that at my age I should not have been given the injection.
Dear Tony:
All the available data suggest that a physician will — over time — actually gain at least as much revenue from practicing active surveillance as he will from operating immediately on a patients with low-risk, localized prostate cancer. However, he would be “deprived” of the immediate, short-term payment for the surgery. There are certainly physicians whose clinical practice appears to be oriented around optimizing their revenue stream in the short term. Personally I try to avoid seeing such physicians.