A study published in the July 2014 issue of Medical Care suggests that most prostate cancer specialists who treat prostate cancer agree that active surveillance is an effective option. However, most phycisians do not recommend it for their own low-risk patients, even if this would be appropriate. Instead, the researchers found that the majority of physicians recommend treatments performed by their own specialty.

Clinicians? framing of disease management options is an important factor in patient decision-making. Confirming this, the study’s authors noted that urologists, for example, are more likely to recommend surgery while radiation oncologists are more likely to recommend radiation therapy. “Given the growing concerns about the overtreatment of prostate cancer, our study has important policy implications about possible barriers to promoting active surveillance and specialty biases about optimal treatment regarding localized prostate cancer,” explained Simon P. Kim, MD, MPH, an assistant Professor of Urology at the Yale School of Medicine and one of the study’s authors. [1][2]

Active Surveillance Effective
The researchers surveyed urologists and radiation oncologists regarding their views on options for low-risk prostate cancer. The study focused on perceptions of active surveillance as an initial approach.

A coordinated, multidisciplinary care involving the patient’s primary care providers as well as specialists may provide a better balance between the risks and benefits of the different treatment approaches…

Monitored for disease progression
Prostate cancer is one of the most common cancers in American men. Based on estimates from the American Cancer Society, it is expected that in 2014 about 233,000 new cases of prostate cancer will be diagnosed. About 29,480 men will die of their cancer (1 in 36). On average, 1 man in 7 will be diagnosed with prostate cancer during his lifetime. [3]

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Prostate cancer occurs primarily in older men with 6 in 10 cases being diagnosed in men aged 65 or older. The disease is rarely diagnosed before age 40.

While prostate cancer can be a serious disease, it progresses very slowly. Most men diagnosed with early-stage disease present with localized disease and won’t actually die from prostate cancer. In fact, more than 2.5 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today. Long-term survival with radiation therapie or surgery is possible.

As an alternative for patients with low-risk prostate cancer, which defined as T1c disease, a prostate-specific antigen (PSA) level less than 10 ng/mL and a Gleason score of 6 or less, active surveillance, which involves close monitoring for disease progression by serial prostate-specific antigen (PSA) testing, digital rectal examinations and prostate biopsies, has become an emerging disease management strategy.

To address the growing concern of overtreatment, a National Institutes of Health (NIH)consensus statement on the role of active surveillance for prostate cancer concluded that active surveillance should be offered to eligible patients with low-risk disease. Approximately 100,000 patients are eligible for such an approach annually.

Active surveillance has emerged as an approach to avoid overtreatment of prostate cancer. In many cases, active surveillance can avoid surgery or radiation therapy that would entail a risk of complications and side effects without actually benefiting the patient.

In their study, the authors tried to find answers why the majority of patients eligible for active surveillance, based on their low risk profile, still undergo primary definitive therapy, which includes surgery or radiation therapy.

In this study, 1,366 North American urologists and radiation oncologists were asked whether active surveillance was effective, whether it was underused, whether their patients were interested in this treatment option, and what there treatment recommendations for low-risk prostate cancer would be. These physicians were randomly selected from a sample of radiation oncologists and urologists from the American Medical Association (AMA) Physician Masterfile in June 2011. [1]

A total of 52.5% (717) of the physicians completed the survey. There was minimal differences between specialties (p=0.92). Kim and his colleagues analyzed survey responses. Consistent with the research evidence, 72% of the specialists agreed that active surveillance is an effective alternative for men with low-risk prostate cancer. In addition, 80% agreed that active surveillance was underused in the United States.

Not recommend for their own patients
“However, 71% of the physicians responded that their patients were not interested in active surveillance,” the researchers write. The rate was over 80% for radiation oncologists, compared to 60% for urologists.

When asked what treatment they would recommend for a hypothetical 60-year-old man with low-risk prostate cancer, just 22% of the physicians said would endorse active surveillance. Instead, 45% would recommend surgery (radical prostatectomy) while 35% would recommend some form of radiation therapy.

In general, the recommendations split along specialty lines?most respondents recommended the treatment provided by their specialty. After adjustment for other factors, urologists were four times more likely to recommend surgery, compared to radiation oncologists. Urologists were also much less likely to recommend any form of radiation therapy.

Urologists vs. radiation oncologists
Urologists were more than twice as likely to recommend active surveillance, compared to radiation oncologists. Doctors who worked in academic medical centers were also more likely to recommend active surveillance.

The survey adds to recent evidence that physicians view active surveillance as a reasonable approach to initial treatment in appropriate patients with low-risk prostate cancer. Both groups of specialists acknowledge the growing concern about overtreatment of prostate cancer.

“[Reasonableness and concern for over treatment] hasn’t consistently translated into their self-reported patterns of treatment recommendations,” Kim noted. “Our study suggests that there remain some key attitudinal barriers to active surveillance among prostate cancer specialists, especially considering radiation oncologists and urologists may view their treatment as superior.”

Patient involvement
The study’s authors also discuss some options to better incorporate patient preferences into treatment decisions?such as decision aids to provide men with evidence-based data on the advantages and disadvantages of treatment options. Coordinated, multidisciplinary care involving the patient’s primary care providers as well as specialists may also provide a better balance between the risks and benefits of the different approaches. “By doing so, active surveillance may become a more acceptable disease management strategy for low-risk prostate cancer among newly diagnosed patients and specialists,” Kim concluded. [4]

For more information:
[1] Perceptions of Active Surveillance and Treatment Recommendations For Low-Risk Prostate Cancer: Results From A National Survey of Radiation Oncologists and Urologists. Kim SP, Gross CP, Nguyen PL, Smaldone MC, Shah ND, Karnes RJ, Thompson RH?, et al. Medical Care, July 2014, 52 (7); 579-585 [Article]
[2] Frendl DM, Sokoloff MH. Clinical and Policy Perspectives on the Adoption of Active Surveillance for Low-risk Prostate Cancer. Medical Care, July 2014, 52 (7); 576-578 [Article]
[3] What are the key statistics about prostate cancer? American Cancer Society. Last visited June 16, 2014 [Website]
[4] Hofland, P. Why a Multidisciplinary Team Approach in Managing Prostate Cancer Makes Sense. Onco’Zine – The International Oncology Network, April 12, 2007 [Article]

Photo: Simon P. Kim, MD, MPH, an assistant Professor of Urology at the Yale School of Medicine, Photo Courtesy:?2014Yale School of Medicine/Yale Cancer Center,New Haven, CT 06520-8028

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