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Whether a man consults with a urologist, a radiation oncologist, or a primary care physician after being diagnosed with clinically localized prostate cancer can lead to different treatment choices.
A study of 85,088 men, aged 65 years and older and diagnosed from 1994 to 2002, found that half saw only a urologist. These patients were more likely to have a radical prostatectomy, primary androgen deprivation therapy, or expectant management. Only 5% went on to radiation therapy.
Fewer than half (44%) of men diagnosed during this time period consulted a radiation oncologist after diagnosis by a urologist. Most men who saw both specialists had radiation therapy. Only 8% underwent radical prostatectomy. Even fewer chose the conservative options of hormone treatment or watchful waiting.
For the most part, men did not visit their primary care physicians after diagnosis. The 17% who did tended to be older and usually opted for a conservative strategy. Just 6% of all men in the study also consulted a medical oncologist. "[Whom you see] does sort of influence what you get," Dr. Thomas L. Jang said after reporting the results.
His presentation generated extensive discussion, as audience members questioned whether the men who consulted radiation oncologists had actually been referred for radiation therapy by their urologists. This, in turn, raised the question of whether urologists were giving men full information on all treatment options before choices were made.
Dr. Jang, a urologist at Memorial Sloan-Kettering Cancer Center, New York, emphasized that no treatment has been proved better than others for early prostate cancer. The results show that treatment choices are strongly associated with which specialists a patient consults, he said, but other factors—such as patient preferences and distance to radiation or surgical facilities—might also play a role.
In response to a question, he said the study also found regional differences, but he did not present those data.
Urologists generally make the diagnosis of prostate cancer and coordinate care. Dr. Jang said he did not recommend that urologists send all prostate cancer patients to consult with both radiation oncologists and medical oncologists. The health care costs would be too great, and it would lessen the efficiency of physician practices.
Rather, he advocated that urologists and radiation oncologists collaborate on standard informational materials that urologists could give to patients. "It is essential that all men with prostate cancer have balanced information prior to making a treatment decision," he said, noting that urologists, radiation oncologists, and medical oncologists collaborated on the study he presented.
Dr. Jang and his coinvestigators matched information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database with Medicare claims and the American Medical Association's Physician Masterfile. They found that for the 8-year period studied, 42% of localized prostate cancer patients aged 65 and older underwent radiation therapy, 21% had a radical prostatectomy, 17% had primary androgen deprivation therapy, and 20% had expectant management.
In general, patients younger than 75 were more likely to have surgery and/or radiation, whereas most of those aged 80 and older opted for more conservative strategies. During the in-between age of 75-79 years, half had radiation therapy, 24% expectant management, 20% primary androgen deprivation therapy, and just 6% radical prostatectomy.
Dr. Jang credited urologists for exercising discretion in that they rarely operated on or ordered radiation therapy for older men with limited life expectancy. Radical prostatectomies were performed in 34% of all 42,309 men who saw only a urologist, but the proportion fell from 70% of those aged 65-69, to 45% of those 70-74, to 10% of those 75-79, and to just 1% of those 80 and older.
In contrast, 83% of 37,540 patients who also consulted a radiation oncologist had radiation therapy. The lowest rate, 78%, was in the group aged 65-69. The rate climbed to 85% of those aged 70-74, and 87% of those aged 75-79, before leveling at 79% of those 80 and older.
Just 14,599 men also visited a primary care physician. Expectant management was the leading treatment in these patients, followed by androgen deprivation.
Even among those who also consulted a urologist and a radiation oncologist, 51% chose watchful waiting, whereas just over a third (34%) opted for radiation therapy. Regardless of which specialists they consulted, fewer than 10% of men who saw a primary care provider decided on surgery.
Dr. Archie Bleyer, moderator of a press briefing on patterns of care, called the study a tour de force. "The results are of concern and affect more men than not," said Dr. Bleyer of St. Charles Medical Center, Bend, Ore.
In a discussion of the study, Dr. Badrinath R. Konety, a urologist at the University of California, San Francisco, said it clearly showed "a differential utilization of expectant management" but also raised many questions.
Expounding on the "counseling vs. consultation issue," he said that patients may choose not to visit other specialists after consulting a urologist. "Lack of consultation may not necessarily mean they were not counseled about the different options," he said.
Dr. Konety sought an explanation for the difference in "treatment vs. no treatment" by specialists consulted, and asked what the role of the rarely consulted medical oncologist should be in early prostate cancer. He also questioned what effect favorable reimbursement for intensity-modulated radiation therapy has had on treatment recommendations.
Another concern, he said, was that 25% of men aged 80-85 received radiation, despite having a life expectancy of 6 years. Surgeons generally will not operate if the patient has a life expectancy of less than 10 years, he said.
Jang T.L. et al. Visits to urologists and radiation oncologists prior to treatment decision making for clinically localized prostate cancer (LCaP). Abstract 6506.
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