Urologists recommend AS more often than rad/oncs (but probably not enough)


A new article on the Medscape web site, based on an article by Kim et al. in the journal Medical Care, deals with urologists’ and radiation oncologists’ recommendations for active surveillance (AS) as an appropriate form of treatment for low-risk prostate cancer in the USA today.

Here are the links to the Medscape article itself and to the full text of the article by Kim et al. in Medical Care.

Basically, Kim et al. surveyed > 1,300 urologists and radiation oncologists (between November 2011 and April 2012) to find out the following:

  • Whether they thought AS was effective and safe as a form of management for low-risk prostate cancer
  • Whether it was under-used on a national basis
  • Whether their patients were interested in AS
  • What their customary treatment recommendations were for low-risk prostate cancer

Her is a summary of what they reported:

  • 717/1,366 physicians (52.5 percent) of physicians completed and returned the survey, with minimal differences between specialties (P = 0.92).
  • Of these 717 physicians
    • 71.9 percent reported that AS is effective.
    • 80.9 percent reported that AS is under-used in the USA.
    • 71.0 percent stated that their patients were not interested in AS.
  • For the treatment of low-risk prostate cancer,
    • 44.9 percent recommended radical prostatectomy.
    • 35.4 percent recommended brachytherapy.
    • 22.1 percent recommended and endorsed AS.
    • Urologists were more likely than radiation oncologists to recommend surgery (odds ratio [OR] = 4.19; P < 0.001) and AS (OR = 2.55; P < 0.001).
    • Urologists were less likely that radiation oncologists to recommend brachytherapy (OR = 0.13; P <0.001) and external beam radiation therapy (OR = 0.11; P < 0.001).

Kim and his colleagues conclude that:

Most prostate cancer specialists in the United States believe AS effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver.

The additional comments in the Medscape article from opinion leaders like Dr. Tony Zeitman (a radiation oncologist at Memorial Sloan-Kettering Cancer Center) make for interesting reading. The full text of the article in Medical Care provides a great deal of additional detail that may be of considerable relevance.

2 Responses

  1. ANOTHER POSSIBLE EXPLANATION FOR LOWER SALIENCE OF AS AMONG RAD/ONCS

    Dr. Zietman mentioned the financial disincentive for rad/oncs recommending AS as contrasted with the ongoing management role of urologists who recommend AS, and that is certainly credible.

    Another factor contributing to the difference in salience could be that rad/oncs may be seeing a somewhat higher risk population. For instance, many of their patients would have likely already interacted with a urologist, who may have referred them for a second opinion if not treatment, whereas the reverse is unlikely to be true. After all, urologists are the gatekeepers, not rad/oncs.

  2. There is no excuse for any patient other than a high-risk patient to undergo any treatment without first being made aware of AS. Then it is not a good excuse.

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

    I think the bigger fear is the time expended if AS is brought up.

    This is why malpractice attorneys argue they do improve medical treatment in the US.

    Very short deposition required:

    “When did you discuss AS with Mr. X?”

    “Oh, it was not appropriate in this case?”

    “Strange, when did you last find it appropriate with any patient? Never?”

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: