Treatment for Localized Prostate Cancer Associated with Type of Specialist Seen
New Brunswick, N.J.– New research to be published in today’s issue of the Archives of Internal Medicine (Vol. 170, No. 5), by an investigator at The Cancer Institute of New Jersey (CINJ) and colleagues at Memorial Sloan-Kettering Cancer Center in New York, shows that the type of specialist that men with localized prostate cancer see can influence the form of therapy they ultimately receive. The study found that patients aged 65 to 69 years old who consult a urologist are more likely to undergo surgery to remove the prostate, while those who consult a radiation oncologist and a urologist, regardless of age, usually receive radiation therapy. CINJ is a Center of Excellence of UMDNJ-Robert Wood Johnson Medical School.
Previous research published in JAMA in 2000 (F.J. Fowler, Jr., et. al.) found that when U.S. urologists and radiation oncologists were surveyed on how they would treat patients with localized prostate cancer, specialists overwhelmingly would recommend the treatment modality that they themselves delivered. However, no evidence to date has determined whether the type of specialist men see after a prostate cancer diagnosis influence the eventual treatment chosen.
This latest study examined 85,088 men aged 65 and older who were diagnosed with localized prostate cancer between 1994 and 2002 using information from the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to determine the type of specialist they saw and the therapy they received. The treatments included radical prostatectomy (surgery to remove the prostate), radiation therapy, primary androgen deprivation (hormone) therapy, and expectant management (an approach also known as watchful waiting, which involves no treatment and frequent monitoring of the patient).
Among the men in the study, 50 percent were seen exclusively by a urologist; 44 percent by both a radiation oncologist and a urologist; three percent by both a medical oncologist and a urologist; and three percent by all three specialists. A high correlation was observed between the type of specialist patients saw and the treatment they received. This was especially true in the younger men aged 65 to 69, where 70 percent of men who saw only a urologist had a radical prostatectomy. However, if men in this group saw a radiation oncologist and a urologist, 78 percent had radiation therapy. If men aged 65 to 69 years old saw a medical oncologist and a urologist, 53 percent had a prostatectomy and nearly equivalent numbers had either radiation therapy (17 percent), expectant management (16 percent), or primary androgen deprivation therapy (14 percent).
Rates of hormone treatment and expectant management increased with age for men evaluated by urologists alone and for those evaluated by both urologists and medical oncologists. However, while only 16 percent of men 75 years or older with prostate cancer visited a radiation oncologist, few of these men were treated expectantly. The authors note that men older than 80 years seldom underwent radical prostatectomy, suggesting that in clinical practice, urologists are sensitive to evidence-based guidelines for the care of elderly men and exercise discretion in the patients to whom they offer curative surgery.
Finally, visits to primary care physicians (PCPs) were infrequent between diagnosis and receipt of therapy, with 22 percent of patients visiting any PCP and 17 percent visiting a PCP with whom there was an established relationship at least 12 months prior to diagnosis. Irrespective of age, unrelated medical conditions, or specialists consulted, men who saw a PCP following diagnosis were more likely to receive expectant management than those patients who did not see a PCP.
“These practice patterns are no surprise but are notable because specialists who treat prostate cancer tend to favor the treatment they themselves deliver, despite the fact that no one has shown one treatment for early stage prostate cancer to be better than another,” said Thomas L. Jang, MD, MPH, urologic oncologist at CINJ, assistant professor of surgery at UMDNJ-Robert Wood Johnson Medical, and the lead author of the study. “It is very important for patients to receive an unbiased, balanced perspective on the full range of treatment options, as the treatments for localized prostate cancer have different side effects and different recovery profiles, and involve a different time commitment.”
The team cautions that because men in the study were older than 65, the findings may not apply to younger patients.
Along with Dr. Jang, the author team consists of Justin Bekelman, MD; Yihai Liu, MS; Peter Bach, MD, MAPP; Ethan Basch, MD, MSc; Elena Elkin, PhD; Michael Zelefsky, MD; Peter Scardino, MD; Colin Begg, PhD; and Deborah Schrag, MD, MPH. All were at Memorial Sloan-Kettering Cancer Center during the time of the study. Dr. Bekelman is now with the Hospital of the University of Pennsylvania in Philadelphia, while Dr. Schrag is currently with the Dana-Farber Cancer Institute in Boston.
This research was funded by a National Institutes of Health Ruth Kirchstein National Research Service Award (T32 CA 82088-07) (Jang) and grants 1F32 CA 123964-01 (Bekelman) and R21 CA98353 (Schrag) from the National Cancer Institute.
According to the American Cancer Society, prostate cancer is the second leading cause of cancer death in men and strikes one in six men. Last year in New Jersey, 6,000 new cases of the disease were diagnosed, with 192,000 new cases nationally. The five-year relative survival rate for men with localized prostate cancer is nearly 100 percent. Treatment side effects vary. The most common are urinary incontinence and erectile dysfunction for prostatectomy; diarrhea and erectile dysfunction for radiation therapy; loss of libido, hot flashes and breast tenderness for hormone therapy. There are no physical side effects associated with watchful waiting.
About The Cancer Institute of New Jersey
The Cancer Institute of New Jersey (www.cinj.org) is the state’s first and only National Cancer Institute-designated Comprehensive Cancer Center dedicated to improving the detection, treatment and care of patients with cancer, and serving as an education resource for cancer prevention. CINJ’s physician-scientists engage in translational research, transforming their laboratory discoveries into clinical practice, quite literally bringing research to life. To make a tax-deductible gift to support CINJ, call 732-235-8614 or visit www.cinjfoundation.org. CINJ is a Center of Excellence of UMDNJ-Robert Wood Johnson Medical School.
The CINJ Network is comprised of hospitals throughout the state and provides a mechanism to rapidly disseminate important discoveries into the community. Flagship Hospital: Robert Wood Johnson University Hospital. Major Clinical Research Affiliate Hospitals: Carol G. Simon Cancer Center at Morristown Memorial Hospital, Carol G. Simon Cancer Center at Overlook Hospital, Cooper University Hospital and Jersey Shore University Medical Center. Affiliate Hospitals: Bayshore Community Hospital, CentraState Healthcare System, JFK Medical Center, Mountainside Hospital, Raritan Bay Medical Center, Robert Wood Johnson University Hospital at Hamilton (CINJ at Hamilton), Saint Peter’s University Hospital, Somerset Medical Center, Southern Ocean County Hospital, The University Hospital/UMDNJ-New Jersey Medical School*, and University Medical Center at Princeton. *Academic Affiliate