Most prostate cancer specialists don't recommend active surveillance for low-risk patients
Specialists who treat prostate cancer agree that active surveillance is an effective option—yet most don't recommend it when appropriate for their own patients, according to a study in the July issue of Medical Care .
Rather, urologists are more likely to recommend surgery and radiation oncologists are more likely to recommend radiation therapy—the treatments provided by their own specialties. "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," comments Dr Simon P. Kim of Yale School of Medicine.
Most Prostate Specialists Rate 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.
Prostate cancer typically progresses slowly—most older men diagnosed with early-stage disease won't actually die of prostate cancer. For these low-risk cases, there's growing interest in active surveillance, in which patients are closely monitored for evidence of disease progression.
Active surveillance has emerged as an approach to avoid "overtreatment" of prostate cancer. In many cases, it can avoid surgery or radiation therapy that would entail a risk of complications and side effects without actually benefiting the patient.
Dr Kim and coauthors analyzed survey responses from 717 US urologists and radiation oncologists. Consistent with the research evidence, 72 percent of the specialists agreed that active surveillance is an effective alternative for men with low-risk prostate cancer. In addition, 80 percent agreed that active surveillance was underused in the United States.
…But Don't Recommend It for Their Own Patients
"However, 71 percent of the physicians responded that their patients were not interested in active surveillance," the researchers write. The rate was over 80 percent for radiation oncologists, compared to 60 percent for urologists.
When asked what treatment they would recommend for a hypothetical 60-year-old man with low-risk prostate cancer, just 22 percent of the physicians said would endorse active surveillance. Instead, 45 percent would recommend surgery (radical prostatectomy) while 35 percent 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 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.
However, "that hasn't consistently translated into their self-reported patterns of treatment recommendations," Dr Kim and colleagues write. "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."
The researchers 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," Dr Kim and coauthors conclude.