Importance: Up-front treatment of older men with low-risk prostate cancer can cause morbidity without clear survival benefit; however, most such patients receive treatment instead of observation. The impact of physicians on the management approach is uncertain.
Objective: To determine the impact of physicians on the management of low-risk prostate cancer with up-front treatment vs observation.
Design, Setting and Participants: Retrospective cohort of men 66 years and older with low-risk prostate cancer diagnosed from 2006 through 2009. Patient and tumor characteristics were obtained from the Surveillance, Epidemiology, and End Results cancer registries. The diagnosing urologist, consulting radiation oncologist, cancer-directed therapy, and comorbid medical conditions were determined from linked Medicare claims. Physician characteristics were obtained from the American Medical Association Physician Masterfile. Mixed-effects models were used to evaluate management variation and factors associated with observation.
Main Outcomes and Measures: No cancer-directed therapy within 12 months of diagnosis (observation).
Results: A total of 2145 urologists diagnosed low-risk prostate cancer in 12 068 men, of whom 80.1% received treatment and 19.9% were observed. The case-adjusted rate of observation varied widely across urologists, ranging from 4.5% to 64.2% of patients. The diagnosing urologist accounted for 16.1% of the variation in up-front treatment vs observation, whereas patient and tumor characteristics accounted for 7.9% of this variation. After adjustment for patient and tumor characteristics, urologists who treat non-low-risk prostate cancer (adjusted odds ratio [aOR], 0.71 [95% CI, 0.55-0.92]; P = .01) and graduated in earlier decades (P = .004) were less likely to manage low-risk disease with observation. Treated patients were more likely to undergo prostatectomy (aOR, 1.71 [95% CI, 1.45-2.01]; P < .001), cryotherapy (aOR, 28.2 [95% CI, 19.5-40.9]; P < .001), brachytherapy (aOR, 3.41 [95% CI, 2.96-3.93]; P < .001), or external-beam radiotherapy (aOR, 1.31 [95% CI, 1.08-1.58]; P = .005) if their urologist billed for that treatment. Case-adjusted rates of observation also varied across consulting radiation oncologists, ranging from 2.2% to 46.8% of patients.
Conclusions and Relevance: Rates of management of low-risk prostate cancer with observation varied widely across urologists and radiation oncologists. Patients whose diagnosis was made by urologists who treated prostate cancer were more likely to receive up-front treatment and, when treated, more likely to receive a treatment that their urologist performed. Public reporting of physicians' cancer management profiles would enable informed selection of physicians to diagnose and manage prostate cancer.
Written by:
Hoffman KE,1 Niu J,2 Shen Y,3 Jiang J,3 Davis JW,4 Kim J,5 Kuban DA,1 Perkins GH,1 Shah JB,3 Smith GL,1 Volk RJ,6 Buchholz TA,1 Giordano SH,2 Smith BD,1 Are you the author?
1Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston.
2Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston.
3Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston.
4Department of Urology, The University of Texas MD Anderson Cancer Center, Houston.
5Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston.
6Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston.
Reference: JAMA Intern Med. 2014 Jul 14. (Epub ahead of print)
doi: 10.1001/jamainternmed.2014.3021
PubMed Abstract
PMID: 25023650
