Shopping for care in the prostate cancer “treatment bazaar”

A recent article (and an associated editorial) in the Archives of Internal Medicine evaluated how visits to specialists and primary care physicians (PCPs) by men with localized prostate cancer are related to treatment choice.

The Archives article is available in full on line, and is worth a read for relatively newly diagnosed patients. For more experienced patients and educators, this article simply confirms what was already widely known: that different specialists have a strong tendency to recommend forms of treatment for prostate cancer that reflect their speciality, and that patients tend to be influenced by such recommendations!

Through the use of the SEER database, Jang et al. identified over 85,000 men diagnosed with localized prostate cancer at an age of 65 years or more between 1994 and 2002. The men were then divided into groups based on their primary form of treatment (which had to be received within 9 months of diagnosis). The common forms of primary treatment available at that time were: radical prostatectomy (18,201/85,088 or 21 percent), radiotherapy (35,925/85,088 or 42 percent), androgen deprivation therapy (14,021/85,088 or 17 percent), and expectant management (16,941/85,088 or 20 percent). Jang et al. also used Medicare claims and other data to assess patients’ visits to various specialists and PCPs.

The results of their analysis showed the following:

  • 42,309/85,088 patients (50 percent) were seen exclusively by urologists.
  • 37,540/85,088 patients (44 percent) were seen by urologists and by radiation oncologists.
  • 2,329/85,088 patients (3 percent) were seen by urologists and by medical oncologists.
  • 2,910/85,088 patients (3 percent) were seen by all three specialists.
  • There was a strong association between the type of specialist seen and the primary therapy received.
  • After diagnosis and before treatment, 22 percent of patients visited any PCP and 17 percent visited an established PCP.
  • Irrespective of age, comorbidity status, or specialist visits, men seen by PCPs were more likely to be treated expectantly.

The authors conclude that visits to specialists correlate strongly with patients’ “choices” for treatment of  localized prostate cancer. They further conclude that “it is essential to ensure that men have access to balanced information before choosing a particular therapy for prostate cancer.”

That’s a wise conclusion, except for one crucial fact: truly straightforward and “balanced” information is very hard to come by because of all the things we don’t know!

There are many in the prostate cancer community who don’t think much of the opinions of Dr. Michael Barry, but in an editorial on this article, in the same issue of the Archives of Internal Medicine, under the title “The prostate cancer treatment bazaar,” Dr. Barry writes: “Few medical decisions are as difficult as the one faced by a man newly diagnosed as having prostate cancer.” (This is about as controversial as saying “Cows make a noise that sounds like ‘mooo.’ “)

Dr. Barry goes over the data presented by Jang et al. some care before, first, making a statement:

  • “The real problem implied by these consultation and treatment patterns is that it does not appear that the underlying decisions reflected effective, patient-centered (let alone efficient) care.”

Secondly, he asks a question:

  • “[H]ow much did patients really know about the likely outcome of all their options, and to what extent did their preferences, rather than the preferences of the specialists they consulted, drive these decisions?”

Finally he gives an opinion:

  • “Fully informing men about their prostate cancer treatment options involves honestly telling men what we do not know as well as the little we do. It requires a shared decision-making process, in which patient preferences, not physician specialty and certainly not physician investment, determine the treatment course.”

The “New” Prostate Cancer InfoLink is in complete agreement with Dr. Barry on these points. Even though there are those who will argue that the Jang article is based on outdated information from over a decade ago, our suspicion is that if we could repeat this study literally today, with data from 2005 to 2010, we would see a very similar pattern of behaviors (although we might want to identify brachytherapy separately from other forms of radiotherapy in the list of treatment options).

We are, however, not quite so sure about Dr. Barry’s statement that, “there is another potential source of good, unbiased information, the PCP.”

There are certainly excellent PCPs who can and would offer such good and unbiased guidance — but then there are also primary care physicians who, because of their own personal opinions and experiences about the diagnosis and treatment of prostate cancer, may not be as capable of offering “good, unbiased” guidance to their patients.

At the end of the day, if you have a PCP with whom you have a long-standing and solid relationship, it certainly would be wise to seek his or her advice before coming to any final decision about treatment for localized prostate cancer, but a visit to a PCP with whom you have no historic relationship may not really be any more constructive than talking to a friend. The friend may know less medicine — but he may know you, the patient, better than any doctor!

One Response

  1. Excellent commentary, as ever.

    It would have been interesting to see the split by treatment chioce in men younger than 65 which I would expect to be primarily RP — or RALP in the last 5 years.

    Apropos the quote “…. patient preferences, not physician specialty and certainly not physician investment, determine the treatment course,” I was reminded of one doctor’s lament that it appeared too many doctors were interested in their income rather than their patient’s outcome.

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