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Physician variation in management of low-risk prostate cancer: a population-based cohort study

Hoffman KE, Niu J, Shen Y, Jiang J, Davis JW, Kim J, Kuban DA, Perkins GH, Shah JB, Smith GL, Volk RJ, Buchholz TA, Giordano SH, Smith BD.

JAMA Intern Med. 2014 Sep;174(9):1450-9



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.


To determine the impact of physicians on the management of low-risk prostate cancer with up-front treatment vs observation.


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.


No cancer-directed therapy within 12 months of diagnosis (observation).


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.


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.

Comment from Henk van der Poel: Do we give impartial advice? Or who is unbiased? Early analyses showed a preferential treatment advice dependent on the main treatment modality provided by a specific physician. Urologist were more likely to provide prostatectomy, whereas radiation oncologist preferentially used radiotherapy and men consulting a medical oncologist were more likely to receive an initial active surveillance management of low and intermediate risk prostate cancer.  In a large cohort of patients (12.000) with low risk prostate cancer diagnosed over the age of 65 year treatment was analyzed. The majority of men (80%) with low risk disease received treatment. Men seen by urologists only, a urologist with more years after training and urologists that treat non-low-risk prostate cancer were all significantly more likely to undergo treatment as opposed to an (active) surveillance approach. In men visiting the radiation oncologist upfront treatment was even higher than for urologists: over 90%. Between 2006 and 2009 an  increasing rate of observation was noted (from 17.5% to 25.1%) indicating that the field is continuously shifting and data from 8 years ago may and should not affect nowadays decision-making on the topic of active surveillance. With an increase in life-expectancy data from the SPCG-4 trial, in some cases even before the PSA era should be interpreted with caution. Although active surveillance adaptation will continue to improve, with longer follow up the “progression” rate leading to active treatment in men initially managed conservatively is shown to exceed 50%. Finally, although urologists seem to advice active treatment in many men with low risk prostate cancer, they don’t stand alone. Also radiation oncologists tend to shy away form active surveillance and perform active treatment in over 90% over referred men with low risk prostate cancer.