When will what they say correspond to what they do?


In reading through the abstracts of the presentations to be given at the upcoming annual meeting of the American Urological Association (AUA), the results of a national survey of radiation oncologists and urologists on active surveillance (AS) for low-risk prostate cancer is the most striking item that we have seen to date.

According to the abstract of the presentation to be given by Kim et al. (on Sunday, May 5; look for abstract no. 547 if you search the AUA abstracts), they conducted a mail survey of 1,439 physicians between late 2011 and early 2012, asking specific questions about physician attitudes associated with the role of AS and other management options for men with classic, low-risk disease (PSA < 10 ng/ml, clinical stage T1c, and Gleason 6).

Here are the findings:

  • 722/1,439 physicians (52 percent) completed and returned the survey (a surprisingly high response rate).
    • 362 were radiation oncologists.
    • 360 were urologists.
  • 72 percent of responders reported that AS is effective for management of low-risk prostate cancer.
    • 78 percent of urologists agreed that AS was effective.
    • 65 percent of radiation oncologists agreed that AS was effective.
    • This difference was statistically significant (p < 0.001).
  • 69 percent of responders stated that they were comfortable routinely recommending AS.
    • 75 percent of urologists were comfortable recommending AS.
    • 62 percent of radiation oncologists were comfortable recommending AS.
    • This difference was statistically significant (p < 0.001).
  • However, when it came to their actual treatment recommendations for low-risk prostate cancer
    • 44 percent of respondents recommended radical prostatectomy.
    • 32 percent recommended radiation therapy.
    • 22 percent recommended AS.
    • Radiation oncologists were much more likely to recommend radiation therapy (odds ratio [OR] = 10.68; p < 0.001).
    • Urologists were more likely to recommend surgery (OR = 4.03; p < 0.001) and half as likely to recommend AS (OR = 2.49; p = 0.001).

Now it is not entirely surprising that radiation oncologists are less likely than urologists to endorse or recommend AS … because they are probably far less likely to actually see patients who will willingly accept AS as an option (because that option has probably already been presented by a urologist). However, as the authors carefully conclude:

Although AS is widely viewed as effective by both radiation oncologists and urologists, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Our results may explain in part the relatively low contemporary use of AS in the U.S.

Anyone think they might understand this dichotomy? (That is a rhetorical question.)

7 Responses

  1. Depending on my upcoming biopsy (saturation), these results may be interesting. My PSA is 7.57 and I’ve gone through two previous biopsies, in 2004 and 2012; both negative. Had a PCA3 test 3 weeks ago at 51. My urologist is recommending the saturation biopsy. My PSA has been in the 5 to 7.5 ng/ml range for 9 years.

  2. They’ll change when it’s profitable for them to change.

  3. ENCOURAGING OPINION CHANGE REGARDING AS

    This appears to be a healthy change toward a more favorable opinion for AS among the urological and radiation communities. I’m wondering what previous surveys have shown.

    Here are a couple more reasons, in addition to Sitemaster’s point, that might account for why urologists appear to be more supportive of AS than radiation oncologists.

    First, I’ll bet radiation oncologists still tend to encounter a greater proportion of patients with more advanced disease, those who would not qualify for AS. Also, the urologists, who almost always get the first “cut” at the patient pool, would tend to cull out some of the patients suitable for AS (both for AS and surgery) before the radiation oncologists even get a chance to talk to them, a point similar to the one Sitemaster is making.

    Second, the major and longer running AS series are all led by prominent urologists and no doubt publish primarily in journals more likely to be read by urologists than radiation oncologists. It would be interesting to know the degree of prominence of AS in the “Education Books” of key advice and guidance on developments that are featured at the annual meetings for urologists and radiation oncologists.

    I suspect Tracy’s point is, unfortunately, also quite valid for many doctors.

  4. I think education may be important here. Family practitioners and internists who more often should be engaged in shared decision making with patients might be more appropriate specialists to follow those who choose active surveillance. Primary care physicians and patients alike need to be educated on when AS is an appropriate option and when referral for treatment is indicated.

  5. CLINICAL EXAMPLE IN SURVEY COULD HAVE BEEN BETTER

    Active surveillance guidance has moved beyond just the criteria traditionally employed for risk classification — PSA, Gleason, and stage, with low-risk disease being a key but no longer the only part of the AS criteria. Unfortunately, these were the only criteria used in the clinical example posed in the survey. While likely already evolving, the consensus at the 2007 meeting of AS experts also included percent of positive cores, PSA velocity, and PSA density (not bone scan result, not CT scan result, and definitely not age by itself!). I would like to see future surveys incorporate those other important features in the clinical example, with perhaps also a nod toward co-morbidities/life expectancy. An interesting variation would be to ask the survey respondents what characteristics they would look for in determining AS eligibility.

  6. AS needs to become a formal and recognized medical specialty to improve training, quality of research and evidence, and cultural acceptance. Question deeply the values and interests of those who oppose AS.

  7. Tracy: It’s already happening. These things take time, however.

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