It was true 3 years ago, but is it still the case?

One of the problems with a lot of research is that it is out of date by the time it is published. The following example may be a classic case in point. And it has serious implications.

Using data from the National Cancer Data Base (NCDB), Lester-Coll et al. have just reported (in Urology, the “Gold Journal”) that if you got diagnosed with low-risk prostate cancer between 2010 and 2013, you were rather more than twice as likely to be managed initially with some form of expectant management (i.e., either active surveillance or watchful waiting) at an academic medical center than you were at a community practice (see also this commentary on the Renal & Urology News web site).

The authors report that, based on their analysis from the NCDB:

  • 91,556 men were diagnosed with low-risk prostate cancer during the 2010 to 2013 time frame.
    • 39,139/91,556 (42.7 percent) were evaluated at academic centers.
    • 52,417/91,556 (57.3 percent) were evaluated at community facilities.
  • 10,880/91,556 (11.9 percent) were initially managed with some form of expectant care (active surveillance or watchful waiting).
  • 80,676/91,556 (88.1 percent) received some form of invasive treatment with curative intent.
  • Expectant management was the initial treatment for
    • 17 percent of patients evaluated at academic centers
    • 8 percent of patients evaluated at community centers (17% vs. 8%, p<0.001).
  • After adjusting for “pertinent covariates”, evaluation at an academic as opposed to a community practice was 2.7 times more likely to lead to the initial use of some form of expectant management.

Now it should be said that this is not entirely surprising for all sorts of possible reasons:

  • Real acceptance of the effectiveness and safety of active surveillance was still in evolution in 2010.
  • Several academic centers had ongoing clinical studies of expectant management ongoing in 2010 to 2013.
  • The incomes of physicians at academic medical centers tend to be less affected by how the patients are actually managed than are those of community practitioners.

The other clear piece of information from this study is that only 12 percent of all low-risk patients were being initially managed on active surveillance or watchful waiting in 2010 to 2013, whereas it is now quite clear that as many as 50 percent or more of all low-risk patients are, in fact, really good candidates for at least initial management on one of other of these types of protocol (although perhaps only 25 percent will remain on such a protocol for long periods of time — because they really do have an indolent form of prostate cancer).

What’s the real message here for patients?

  • In 2010 to 2013, expectant management was still a seriously under-used form of care for men with low-risk prostate cancer.
  • Far too many men with low-risk prostate cancer were still being placed at risk for over-treatment during that time frame because (for whatever reason) they were having initial treatment that they didn’t necessarily require.
  • Such risk for over-treatment was greater in community settings than at academic medical centers.

But perhaps much more importantly, we need to know how much has changed between 2013 and today. The evidence in support of the initial application of expectant management as an appropriate form of care for any man with low-risk prostate cancer is now overwhelming. Arguably, the failure to explain to a newly diagnosed patient with low-risk prostate cancer that some form of expectant management is (or at least may be) an entirely appropriate first-line option is unethical and immoral too.

6 Responses

  1. Dear David:

    The ability and desire of “experts” (not to mention the rest of us) to believe in and promulgate what they (and we) want to believe is hardly limited to health care.

    As an example of one that will undoubtedly upset at least one or two readers, I am still waiting for anyone to provide me with any absolute and meaningful evidence for the existence of “God” — which does not mean that I don’t think that many of the better precepts of numerous religions (e.g., “Thou shalt not kill”, “Do unto others as you would be done by”) aren’t highly appropriate. However, I find much of what goes on in the name of religious belief to be absolutely horrifying.

  2. One factor to consider is, “How accurate is the low-risk classification?” The treating doctor should have the flexibility to exercise judgment. For example, consider a patient who has another 25 years of life expectancy, the PSA is above 9, and the condition changed from “no cancer” to “cancer in most lobes at Gleason 6” between two successive biopsies. On the basis of published guidelines which are based on averages over a sizeable population, the case could be classified as low risk. However, subjecting the individual case to statistical distribution over a sizeable population is not fair to the individual.

  3. Careful, Sitemaster. I’ve experienced what can happen when religion or politics are brought into discussion when support forums for prostate cancer should avoid these issues because they are too controversial.

    As to physicians explaining to patients with low development the option for active surveillance rather than too early move to aggressive treatment, I believe it is improving since the USPSTF brought attention to over-treatment and pretty much used that problem to nearly shut down consideration for PSA testing. The over-treatment definitely was occurring with urologists as well as radiation oncologists urging men diagnosed with prostate cancer at any Gleason score level, as well as low developing prostate cancer, to have immediate surgical removal or radiation treatment. At least the USPSTF study got people opening their eyes and brought about more of an interest in “active surveillance” as opposed to “watchful waiting,” with subsequent studies occurring providing encouragement to particularly urologists, as the specialists, who are most likely to do the testing and diagnostics to determine the level of development, to pointedly discuss active surveillance as an important option for those men found with low and slow development in order to avoid the side effects that come with surgical removal of or radiation to the prostate gland. Despite this reasonable option, there will be those men who cannot stand the knowledge that there is “cancer” of any level in their body and ignore the side effects they may experience years before this would likely be necessary, and will insist on surgical removal, radiation, or cryotherapy.

  4. Dear Sushil:

    No one is suggesting that the patient has to be treated a certain way. However, the patient quite certainly has the right to know and understand all of his options — even if he is only to be on active surveillance for a few months.

  5. Dear Chuck:

    I can assure you that my choice of words was very careful and very deliberate.

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