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Management of low-risk prostate cancer varied greatly by physician
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The rate at which physicians managed low-risk prostate cancer with observation vs. upfront treatment varied considerably during a recent 4-year period, according to results of a retrospective study.
The diagnosing urologist accounted for a greater percentage of the variation than patient and tumor characteristics, results showed.
“There is meaningful physician-level variation in the management of low-risk prostate cancer,” Karen E. Hoffman, MD, MHSc, MPH, assistant professor in the department of radiation oncology at The University of Texas MD Anderson Cancer Center, and colleagues wrote. “Public reporting of physicians’ cancer management profiles would enable primary care physicians and patients to make more informed decisions when selecting a physician to diagnose and manage prostate cancer.”
Karen E. Hoffman
Most older men with low-risk prostate cancer undergo upfront treatment, even though it can lead to substantial morbidity without a clear survival benefit, according to background information provided by the researchers.
Hoffman and colleagues conducted their study to assess the impact of physicians on management of low-risk prostate cancer. They used SEER cancer registries to identify men aged 66 years or older diagnosed with low-risk prostate cancer between 2006 and 2009.
Hoffman and colleagues used Medicare claims data to determine the diagnosing urologist, consulting radiation oncologist, cancer-directed therapy and patient co-morbidities. They used the American Medical Association Masterfile to obtain physician characteristics.
The analysis included 12,068 patients, all of whom received their prostate cancer diagnosis from a urologist (n=2,145). The majority of patients (80.1%) underwent treatment, whereas 19.9% underwent observation, defined as no cancer-directed therapy within 12 months of diagnosis.
Researchers determined the case-adjusted rate of patients who underwent observation varied greatly across urologists (range, 4.5% to 64.2%) and across consulting radiation oncologists (range, 2.2% to 46.8%).
Hoffman and colleagues determined the diagnosing urologist accounted for about 16.1% of the variation in upfront treatment choice, whereas patient and tumor characteristics accounted for 7.9% of the variation.
After researchers adjusted for patient and tumor characteristics, they determined urologists who treat non–low-risk prostate cancer (adjusted odds ratio [aOR]=0.71; 95% CI, 0.55-0.92) and those who graduated in earlier decades (P=.004) were less likely to manage low-risk disease with observation.
Results showed patients who received upfront treatment were more likely to undergo cryotherapy (aOR=28.2; 95% CI, 19.5-40.9), brachytherapy (aOR=3.41; 95% CI, 2.96-3.93), prostatectomy (aOR=1.71; 95% CI, 1.45-2.01) or external-beam radiotherapy (aOR=1.31; 95% CI, 1.08-1.58) if their urologist billed for those particular treatments.
“These findings strongly suggest that physicians substantially influence not only decision-making regarding upfront treatment vs. observation but also the type of upfront treatment when treatment is selected,” Hoffman and colleagues wrote. “Our findings have implications for policymakers, primary care physicians and patients.”
Disclosure: The researchers report research support from Varian Medical Systems and the American Society for Radiation Oncology.
Perspective
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Donald L. Trump, MD, FACP
The article by Hoffman and colleagues illustrates a concept that might be referred to as The Kaplan–Maslow Principle.Abraham Kaplan articulated what he called “the law of the instrument.” Kaplan noted: “Give a small boy a hammer, and he will find that everything he encounters needs pounding” (Maslow AH. Psychology of Science. Joanna Cotler Books; 1966). Abraham Maslow described a similar principle more bluntly: “If all you have is a hammer, everything looks like a nail” (Kaplan A. The Conduct of Inquiry: Methodology for Behavioral Science. San Francisco, A: Chandler Publishing Co.; 1964).
Hoffman and colleagues queried the SEER database to identify more than 12,000 men aged older than 66 years who were diagnosed with “low-risk” prostate cancer (Gleason score <6, PSA <10, cT1 or cT2). The researchers linked SEER data to Medicare claims data, and they identified 2,145 urologists as the diagnosing physicians. Patient- and urologist-specific characteristics were examined to evaluate factors associated with a recommendation for observation. Recall observation is the sole National Comprehensive Cancer Network recommendation for men with life expectancy <10 years, and it is an option for all patients with these characteristics.
Eighty percent of patients received active therapy. Marked variation was observed among urologists in the frequency with which observation was recommended. In my view, variation is an enemy of improved outcomes and enhanced value in cancer management. In sensitivity analysis, urologist factors were two times more influential on management option choice than patient factors. An important “urologist-associated factor” influencing choice of active therapy was graduation in earlier decades — so, the Kaplan–Maslow principle in action.
However, more importantly, this paper offers an opportunity for reflection, not just cynicism. If we agree that observation is an appropriate management option for men with low-risk prostate cancer, and that active therapy in such men is a driver of unnecessary morbidity and increased health care expenditures, how do we change the equation? What are the improved education modules and communication strategies to disseminate the most recent data? This is a critical research topic.
Finally, and perhaps most challenging, are there health policy approaches that can be implemented to reduce the incentives to “do something” in such men? If we are to reduce patient morbidity and increase the value of the care we provide men with low-risk prostate cancer, both courses must be followed.
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