Specialist Type Influences PCa Therapy Choice
Men with clinically localized prostate cancer (PCa) who consult with both a radiation oncologist and urologist, regardless of their age, usually receive radiation treatment as their primary therapy, whereas younger men who visit exclusively with a urologist most often receive surgery, according to researchers.
Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, Thomas L. Jang, MD, MPH, of the Cancer Institute of New Jersey in New Brunswick, and collaborators identified 85,088 men with clinically localized PCa diagnosed at age 65 years and older. They categorized the subjects by the primary therapy they received within nine months of diagnosis: radical prostatectomy (RP), radiotherapy, androgen deprivation, and expectant management.
Of the 12,248 men aged 65 to 69 years who consulted with a urologist only, 70% received radical prostatectomy, whereas 78% of the 37,540 men who saw a radiation oncologist and urologist received radiotherapy, the investigators reported in Archives of Internal Medicine (2010;170:440-450). Older men, particularly those older than 75 years who were seen by urologists with or without medical oncologists were more likely than those evaluated by radiation oncologists and urologists to receive more conservative management, such as androgen deprivation or expectant management.
For example, of men aged 80 to 84 years who saw a urologist exclusively, 1% received RP, 2% received radiotherapy, 51% received androgen deprivation, and 46% received expectant management. In contrast, of men in this age group who saw a radiation oncologist and urologist, 1% received RP, 81% received radiotherapy, 10% received androgen deprivation, and 8% received expectant management.
Finally, the authors noted that visits to primary care physicians (PCPs) were infrequent during the decision window period, with only 22% of men seeing a PCP. Regardless of age, concurrent medical illnesses or the type of specialist seen, men seen by PCPs were more likely to be treated expectantly.
"Specialist visits relate strongly to prostate cancer treatment choices," the authors concluded. "In light of these findings, prior evidence that specialists prefer the modality they themselves deliver and the lack of conclusive comparative studies demonstrating superiority of one modality over another, it is essential that men have access to balanced information before choosing a particular therapy for prostate cancer."
In an accompanying editorial, Michael J. Barry, MD, of the Foundation for Informed Medical Decision Making in Boston, observed: "Fully informing men about their prostate cancer treatment options involves honestly telling men what we do not know as well as the little we do."
This requires a shared decision-making process in which patient preferences and not physician specialty or physician investment determine the treatment course, he wrote. n