Type of specialist that men with prostate cancer see can influence form of therapy they ultimately receive

The Cancer Institute of New JerseyMar 9 2010

New research published in today's issue of the Archives of Internal Medicine (Vol. 170, No. 5), by an investigator at The Cancer Institute of New Jersey (CINJ) and colleagues at Memorial Sloan-Kettering Cancer Center in New York, shows that the type of specialist that men with localized prostate cancer see can influence the form of therapy they ultimately receive. The study found that patients aged 65 to 69 years old who consult a urologist are more likely to undergo surgery to remove the prostate, while those who consult a radiation oncologist and a urologist, regardless of age, usually receive radiation therapy. CINJ is a Center of Excellence of UMDNJ-Robert Wood Johnson Medical School.

Previous research published in JAMA in 2000 (F.J. Fowler, Jr., et. al.) found that when U.S. urologists and radiation oncologists were surveyed on how they would treat patients with localized prostate cancer, specialists overwhelmingly would recommend the treatment modality that they themselves delivered. However, no evidence to date has determined whether the type of specialist men see after a prostate cancer diagnosis influence the eventual treatment chosen.

This latest study examined 85,088 men aged 65 and older who were diagnosed with localized prostate cancer between 1994 and 2002 using information from the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to determine the type of specialist they saw and the therapy they received. The treatments included radical prostatectomy (surgery to remove the prostate), radiation therapy, primary androgen deprivation (hormone) therapy, and expectant management (an approach also known as watchful waiting, which involves no treatment and frequent monitoring of the patient).

Among the men in the study, 50 percent were seen exclusively by a urologist; 44 percent by both a radiation oncologist and a urologist; three percent by both a medical oncologist and a urologist; and three percent by all three specialists. A high correlation was observed between the type of specialist patients saw and the treatment they received. This was especially true in the younger men aged 65 to 69, where 70 percent of men who saw only a urologist had a radical prostatectomy. However, if men in this group saw a radiation oncologist and a urologist, 78 percent had radiation therapy. If men aged 65 to 69 years old saw a medical oncologist and a urologist, 53 percent had a prostatectomy and nearly equivalent numbers had either radiation therapy (17 percent), expectant management (16 percent), or primary androgen deprivation therapy (14 percent).

Rates of hormone treatment and expectant management increased with age for men evaluated by urologists alone and for those evaluated by both urologists and medical oncologists. However, while only 16 percent of men 75 years or older with prostate cancer visited a radiation oncologist, few of these men were treated expectantly. The authors note that men older than 80 years seldom underwent radical prostatectomy, suggesting that in clinical practice, urologists are sensitive to evidence-based guidelines for the care of elderly men and exercise discretion in the patients to whom they offer curative surgery.

Finally, visits to primary care physicians (PCPs) were infrequent between diagnosis and receipt of therapy, with 22 percent of patients visiting any PCP and 17 percent visiting a PCP with whom there was an established relationship at least 12 months prior to diagnosis. Irrespective of age, unrelated medical conditions, or specialists consulted, men who saw a PCP following diagnosis were more likely to receive expectant management than those patients who did not see a PCP.

"These practice patterns are no surprise but are notable because specialists who treat prostate cancer tend to favor the treatment they themselves deliver, despite the fact that no one has shown one treatment for early stage prostate cancer to be better than another," said Thomas L. Jang, MD, MPH, urologic oncologist at CINJ, assistant professor of surgery at UMDNJ-Robert Wood Johnson Medical, and the lead author of the study. "It is very important for patients to receive an unbiased, balanced perspective on the full range of treatment options, as the treatments for localized prostate cancer have different side effects and different recovery profiles, and involve a different time commitment."

The team cautions that because men in the study were older than 65, the findings may not apply to younger patients.