Using guidelines published by the National Comprehensive Cancer Network (NCCN), this is the first study to investigate the association between urologist characteristics and radiation oncologist consultation for patients with locoregional prostate cancer.
By utilizing the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database and the American Medical Association Physician Masterfile, our study found that overall, 62% of patients consulted a radiation oncologist within nine months after cancer diagnosis. Patients diagnosed by older urologists were more likely to consult a radiation oncologist. Particularly, patients diagnosed by urologists in non-institutional settings were more likely to consult a radiation oncologist compared with those diagnosed by urologists in institutional settings with a major medical school affiliation.
Our study was published in light of the ongoing debate about prostate cancer over treatment, with its attendant potentially detrimental implications for patient outcomes and costly U.S. health care expenditures. The issue of over treatment may be exacerbated with some urology groups that integrated intensity-modulated radiation therapy (IMRT), an expensive form of external beam radiation therapy, into their practice. Another recently published research(1) that showed an increased use of IMRT by self-referring urology-radiation oncology groups when compared to patients treated in NCCN centers. Such NCCN centers are more likely to have physicians who have major medical school affiliation, whereas physicians who are part of urology-radiation oncology groups are more likely to practice in non-institutional settings (and may not have a major medical school affiliation). A 2013 US Government Accountability Office (GAO)’s report also detailed the higher use of costly prostate cancer radiation treatment by self-referring providers. Our findings may shed further light on the determinants of radiation oncologist consultations before such IMRT self-referrals.
A 2012 GAO report that investigated advanced imaging self-referral concerns noted that “financial incentive for providers to self-refer is most direct when the service is performed in a physician office.”(3) In our study, as expected, greater than 90% of patients diagnosed by non-institutional affiliated urologists received biopsies in physician office settings. That GAO report also found that between 2004 and 2010, the greatest increase in computed tomography self-referral rates occurred among urology and radiation oncology providers.
Our current research also complements our two prior studies that investigated the association of physician practice affiliation and patient clinical treatment.
• Patients treated by non-medical school-affiliated urologists were significantly more likely to receive non-evidence-based androgen deprivation therapy compared to patients treated by urologists with a major medical school affiliation.(4)
• For a majority of the SEER regions, patients treated by non-institutional affiliated radiation oncologists were more likely to receive guideline-discordant combined radiation therapy compared to patients treated by radiation oncologists with a major medical school affiliation.(5)
Further research is necessary to confirm whether subsequent radiation oncologist consultations reflect index urologist referral behavior, patient response, or urologist-patient interactions. Without a gold standard for prostate cancer treatment, urologists’ recommendations and referrals can be crucial in determining eventual treatment. Inherent differences in specialty-related treatment recommendations underscore the importance of obtaining second opinions from different types of specialists before selecting a specific treatment modality. Nevertheless, variation observed in this study should ideally be from the collective preferences and consents of well-informed patients and patient-centered clinical judgment of their physicians.
Ruben G. W. Quek, PhD
Department of Health Policy and Management, Emory University
Viraj A. Master, MD, PhD, FACS
Winship Cancer Institute
Department of Urology, Emory University