Physicians’ attitudes and the management of low-risk prostate cancer in older American men

According to newly published data in JAMA Internal Medicine and discussed on the Reuters web site today, “physician characteristics may play a larger role than disease characteristics when it comes to how patients with low-risk prostate cancer are initially treated.” This won’t come as a big surprise to most experienced prostate cancer advocates.

The new paper by Hoffman et al. used data from the interlinked Surveillance, Epidemiology, and End Results (SEER)-Medicare registries to assess the impact of physicians on the initial management of men of 66 years of age and older with low-risk prostate cancer.

Relevant data was extracted from the SEER-Medicare database for men diagnosed between 2006 and 2009. Such data included patient and tumor characteristics, the identities of the diagnosing urologist and the consulting radiation oncologist (if any), the type of cancer-directed therapy, and any co-morbid conditions of the patient. Additional information about the physicians was extracted from the American Medical Association Physician Masterfile.

Here are the key study findings:

  • 2,145 urologists diagnosed low-risk prostate cancer in 12,068 men.
  • 80.1 percent of these patients were given some form of active treatment
  • 19.9 percent of the patients were observed in some manner (potentially including active surveillance or watchful waiting).
  • The so-called “case-adjusted rate” of patient observation (i.e., the percentage of patients who a specific urologist simply observed as opposed to actively treating) varied between 4.5 to 64.2 percent.
  • In assessing “accountability” for this variation in up-front treatment as opposed to observation
    • 7.9 percent was accounted for by patient factors (e.g., age and co-morbid conditions) and tumor characteristics.
    • 16.1 percent was accounted for by the urologist.
  • After adjustment for patient and tumor characteristics, it appears that
    • Urologists who treat non–low-risk prostate cancer were less likely to manage low-risk disease with observation (adjusted odds ratio [aOR] = 0.71).
    • Urologists who graduated in earlier decades (i.e., older urologists) were less likely to manage low-risk disease with observation.
    • Treated patients were more likely to undergo a specific type of treatment if their urologist billed for that treatment:
      • Prostatectomy, aOR =1.71
      • Cryotherapy, aOR = 28.2
      • Brachytherapy, aOR = 3.41
      • External-beam radiotherapy, aOR = 1.31
  • Case-adjusted rates of observation also varied across consulting radiation oncologists, ranging from 2.2 to 46.8 percent of patients.

Given that immediate up-front treatment of older men with low-risk prostate cancer can cause morbidity without there being any certainty of a survival benefit (or a quality of life benefit either), it is disturbing to see the degree to which inbuilt biases of a variety of types may have been influencing the potential for over-treatment in the period from 2006 to 2010. And there is little reason to believe that it may not be doing so still.

The authors note in their conclusions that,

Public reporting of physicians’ cancer management profiles would enable informed selection of physicians to diagnose and manage prostate cancer.

Whether such public reporting is likely to happen is a rather different issue. We suspect that many physicians would consider such public reporting of management profiles for any disorder to be unacceptable, so we don’t hold out much hope for such public accountability in the short term.

On the other end of the scale. Dr. H. Ballentine Carter of Johns Hopkins, a recognized authority on the application of expectant management of low- and very low-risk prostate cancer, is quoted by Reuters as follows:

The rate of treatment of older men with low-risk disease is well documented to be extremely high. I think patients need to be aware [of this]. They may never become aware before they undergo treatment. I think we need to do a better job of educating older individuals with low-risk disease.

According to Reuters, Dr. Carter went on to add that “the question should not be which treatment men need but whether they need to be treated.”

2 Responses

  1. It’s neither PSA screening nor testing that results in over-treatment — it’s how that information is communicated to the patient!

  2. Sitemaster,

    Thanks so much for sharing.

    Yikes! This documents the over-treatment and the bias, by specialty.

    Be well :-)


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