United States radiation oncologists’ and urologists’ opinions about screening and treatment of prostate cancer vary by region

doi:10.1016/S0090-4295(02)01832-0

Urology

Volume 60, Issue 4, October 2002, Pages 628-633

https://doi.org/10.1016/S0090-4295(02)01832-0 Get rights and content

Abstract

Objectives

To examine whether physicians’ views on prostate cancer screening and treatment vary by geographic region in the United States.

Methods

A mail survey was sent in 1998 to a random sample of physicians in the United States who were listed as radiation oncologists (response rate 76%, n = 559) and urologists (response rate 64%, n = 504) in the American Medical Association Registry of Physicians and practicing at least 20 hr/wk.

Results

Radiation oncologists and urologists in Florida were more likely to report recommending routine prostate-specific antigen testing for men aged 75 years and older than were their colleagues in other regions of the United States. The Florida physicians were more likely to report treating at least 20% of their patients with brachytherapy and to report believing that brachytherapy has survival value for men with a less than 10-year life expectancy. No regional differences were found in the radiation oncologists’ and urologists’ beliefs about the survival value of radical prostatectomy; however, for men with a less than 10-year life expectancy, Florida urologists had more confidence in the survival benefit of external beam radiotherapy than urologists in other regions (P = 0.04). Radiation oncologists in Florida reported higher rates of recommending early androgen deprivation for a rising PSA after both radiotherapy and surgery (P = 0.008 and P = 0.001, respectively) than did their colleagues in other regions.

Conclusions

Florida radiation oncologists and urologists reported beliefs and practices that differed from their colleagues in other regions of the United States. Whether the distinctive style of prostate cancer diagnosis and treatment in Florida results in improved outcomes has yet to be proved.

Section snippets

Material and methods

A random sample of physicians listing their specialty as radiation oncology or urology was selected from the American Medical Association Master List of Physicians. The sampled physicians’ offices were contacted by telephone to verify their address and specialty, that they were not in residency training, and that they were in clinical practice for at least 20 hours weekly. Pediatric urologists were excluded. The details of the survey method have been previously published.1

We focused our

Survey respondent characteristics

Questionnaires were returned by 76% of radiation oncologists (n = 559) and 64% of urologists (n = 504). Eight radiation oncologists and four urologists were excluded because of missing information concerning region. Table I compares the characteristics of the respondents by specialty across the regions of the United States. Compared with radiation oncologists elsewhere, Florida radiation oncologists were younger, spent more time in clinical practice, and were less likely to be working at a

Comment

For several controversial areas in prostate cancer screening and treatment, we found that radiation oncologists and urologists in Florida differed from their colleagues in other regions of the United States. These Florida subspecialists reported views and practices consistent with Medicare claims data, which show, in general, that Florida physicians use more resources and have higher per capita expenditures than elsewhere in the United States.8, 9, 10

Radiation oncologists and urologists in

Conclusions

Florida radiation oncologists and urologists reported beliefs and practices that differ from the same subspecialists in other United States regions, although they are exposed to the same literature and the same clinical studies. Advocating PSA tests to detect prostate cancer in older men, treating patients with prostate cancer with brachytherapy, believing in the value of aggressive treatment for patients with a less than 10-year life expectancy, and frequently using early androgen deprivation

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Cited by (21)

Organisation of Prostate Cancer Services in the English National Health Service
2016, Clinical Oncology
Citation Excerpt :
In England, more than half specialist MDTs offer these specialist clinics. The opportunity for a patient to see both a urologist and an oncologist at the same clinic visit is particularly important given the variation that exists between urologists and oncologists in their recommendations for the treatment of localised and locally advanced prostate cancer [35–37]. The results of the organisational survey can also be used to assess the wider regional variation in the provision of services in England.
The National Prostate Cancer Audit (NPCA) started in April 2013 with the aim of assessing the process of care and its outcomes in men diagnosed with prostate cancer in England and Wales. One of the key aims of the audit was to assess the configuration and availability of specialist prostate cancer services in England.
In 2014, the NPCA undertook an organisational survey of all 143 acute National Health Service (NHS) Trusts and 48 specialist multidisciplinary team (MDT) hubs cross England. Questionnaires established the availability and location of core diagnostic, treatment and patient-centred support services for the management of non-metastatic prostate cancer in addition to specific diagnostic and treatment procedures that reflect the continuing evolution of prostate cancer management, such as high-intensity focused ultrasound (HIFU) and stereotactic body radiotherapy.
The survey received a 100% response rate. The results showed considerable geographical variation with respect to the availability of core treatment modalities, the size of the target population and catchment areas served by specialist MDT hubs, as well as in the uptake of additional procedures and services. Specifically there are gaps in the availability of core radiotherapy procedures; high dose rate and low dose rate brachytherapy are available in 44% and 75% of specialist MDTs, respectively. By comparison, there seems to be a relative ‘over-penetration’ of surgical innovation, with 67% of specialist MDTs providing robotic-assisted laparoscopic prostatectomy and 21% HIFU. There is also evidence of increased centralisation of core surgical procedures and regional inequity in the availability of surgical innovation across England.
The organisational survey of the NPCA has provided a comprehensive assessment of the structure and function of specialist MDTs in England and the availability of prostate cancer procedures and services. As part of the prospective audit, the NPCA will assess the effect of the availability of prostate cancer services on access regionally and subsequent outcomes of care according to evidence-based guidelines.
Characterization and adequacy of the use of radiotherapy and its trend in time
2013, Radiotherapy and Oncology
Citation Excerpt :
The ARR in prostate cancer is difficult to determine due to the different therapeutic options available with similar health results. Referral to RT is clearly associated with the preference of the urologists, and a large variability has been registered around the world [20]. Our figure of 52% in 2007–2008 is nearer to the considered optimal by the EBEST groups (Fig. 1).
Characterization of radiotherapy activity and its trend over time. Gathering of parameters for future planning of our resources, applicable to similar population areas. Performing a clinical audit of appropriate use of radiotherapy.
Analysis of 9782 patients treated between 1998 and 2008. Descriptive statistics of pathologies and social/demographic characteristics. Intention of treatment. The rate of radiotherapy utilization was estimated and compared with those considered optimal. Rate of reirradiation.
The average global rate of radiotherapy utilization for the period was 32.7%. It increased by 23% between 1998 and 2008, while the population of the area rose by 1.04%, equaling an average 1.13 irradiations/1000 inhabitants/year. Radiation treatment has increased by 13.6, 2.3, 1.6 and 1.06 times in patients with prostate, breast, rectal and lung cancer, respectively. Eight percent of radiotherapy treatments involve concurrent chemotherapy. The proportion of treatments with palliative intent was 18.2%. The overall underutilization of radiation therapy in our environment was an estimated 13.4%.
The grade of adequacy of radiation rates in relation with scientific evidence was globally considered suboptimal, especially in lung cancer. There was an upward trend of irradiation in breast and prostate cancer, tending toward rates considered optimal.
A population-based study on the utilisation rate of primary radiotherapy for prostate cancer in 4 regions in the Netherlands, 1997-2008
2011, Radiotherapy and Oncology
Citation Excerpt :
In the US study, age seemed to be a more important factor influencing the utilisation rate of RT compared to geographic location, which was only an important explanation of the variation in the utilisation rate of RT for the youngest and oldest age groups [16]. In another study in the US, a survey among radiation oncologists and urologists was performed [6]. They found significant regional differences in the selection of patients for EBRT and BT.
The purpose was to study variations in utilisation rates of external beam radiotherapy (EBRT) and brachytherapy (BT) for prostate cancer patients.
We calculated the proportion and number of EBRT and BT given or planned within 6 months of diagnosis in 4 Dutch regions, according to stage and age in a population-based setting including 47,259 prostate cancer patients diagnosed from 1997 until 2008.
During this study period, the overall utilisation rate of EBRT remained stable at around 25%, while the rate of BT for non-metastasized patients increased from 1% (95% CI:0–1%) to 12% (11–13%) in 2006 and slightly decreased towards 10% (9–11%) in 2008. From 2001 on, the overall utilisation rate of EBRT decreased significantly in one region (p < 0.05). In this region, a sharp rise in the utilisation rate of BT for non-metastatic patients was noted to 17% (14–20%) in 2008 after a peak of 24% (21–27%) in 2006. For localised disease, BT was used more often at the expense of EBRT while for locally advanced disease the utilisation rate of EBRT increased. In the multivariate analysis, regional differences in the utilisation rate of EBRT persisted with odds ratios ranging from 0.7 to 0.9 compared to the reference region. Moreover, low rates of EBRT were associated with high BT rates. The regional differences could not be explained by differences in risk profiles.
The utilisation rate of EBRT remained stable with limited variation between regions while BT was used increasingly with clear regional differences. To cope with this and in view of the increasing incidence of prostate cancer, adequate resources have to be planned for the optimal care of these patients.
Clinical Judgment Analysis of the Parameters Used by Consultant Urologists in the Management of Prostate Cancer
2007, Journal of Urology
Citation Excerpt :
Despite these differences there was an overall trend toward recommending radiotherapy or active surveillance for the 70 cases studied with radical prostatectomy the least commonly recommended therapy. Such differences in treatment preference have been previously reported and they appear to relate to patient age, comorbidity, clinician specialty, experience with performing specific procedures or the country of practice.12–14 However, until now little has been reported about the influence of more objective factors on clinician decisions.
We assessed which clinical parameters consultant urologists use to recommend treatment for early prostate cancer.
A total of 30 consultant urologists reviewed 70 paper representations of patients with prostate cancer. Each contained 7 commonly available cues, including prostate specific antigen, Gleason grade, rectal examination, magnetic resonance imaging/laparoscopic stage, medical history, patient choice and age, in addition to 2 cues not yet routinely available, that is predicted life expectancy and 10-year survival probability, as calculated using actuarial formulas based on noncancer comorbidity. Consultants indicated how strongly they would recommend radical prostatectomy, radiotherapy with or without hormones, or active surveillance/hormones. Judgment analysis was performed using multiple regression analysis with significance considered at p ≤0.01 to identify which cues consultants had used.
Consultants varied in the treatments that they recommended. An average of only 3 of the possible 9 cues was used to formulate decisions. Prostate specific antigen and predicted 10-year survival probability were most commonly used for recommending all 3 treatment options. Patient choice, predicted life expectancy, rectal examination and age were all used infrequently. Consultants were inconsistent in an average of 31.4% of judgments when repeat cases were analyzed with the greatest inconsistency observed when recommending radiotherapy with or without hormones and the least inconsistency when recommending radical prostatectomy.
Consultants were inconsistent in their decisions regarding the management of early prostate cancer and they used only a small number of available clinical parameters. Ensuring that all relevant information is available and providing clinicians with further education and training would ensure that treatment decisions become more reliable, appropriate and targeted toward patient choice.
Use of medications or devices for erectile dysfunction among long-term prostate cancer treatment survivors: Potential influence of sexual motivation and/or indifference
2006, Urology
To evaluate the potential association between sexual motivation and patterns of erectile dysfunction (ED) therapy among a large cohort of localized prostate cancer treatment survivors.
The use of medications and devices to improve erections and sexual health-related quality of life (HRQOL) were evaluated using a mailed Expanded Prostate Cancer Index Composite survey administered to 896 men 4 to 8 years after brachytherapy, three-dimensional conformal external beam radiotherapy (3D-CRT), or radical prostatectomy and 112 control men. The responding participants (73% of those surveyed) were classified by prostate cancer treatment, sexual motivation, and ED therapy use. Bivariate and multivariate analyses were used to identify the factors associated with ED therapy use and sexual HRQOL outcome.
The quality of erections unassisted by medications or devices was not different among the treatment groups. Prostate cancer survivors used medications or devices for ED more commonly than did the control men (30% versus 13%; P <0.01). One half of the prostate cancer survivors with ED reported indifference regarding their ED (small to no sexual bother despite absent or poor unassisted erections). Conversely, among men who were bothered by poor erections, 48% of the brachytherapy, 61% of the 3D-CRT, and 23% of radical prostatectomy subjects had never tried commonly available medications or devices to improve their erections (P <0.01). The current use of at least one erection aid was an independent determinant of more favorable sexual HRQOL (P <0.01).
Many men who are bothered by posttreatment ED reported never having tried medications or devices to improve their erections. The lack of ED therapy was more prevalent among patients with erectile concerns after brachytherapy or 3D-CRT than after radical prostatectomy, suggesting possible opportunities for improving sexual HRQOL among long-term survivors.
Hospital variation in referral for primary radiotherapy in South Netherlands, 1988-1999
2005, European Journal of Cancer
In this study, we have assessed whether referral for primary radiotherapy varied according to hospital size in a region with 1 million inhabitants served by community hospitals. We studied 20 178 patients diagnosed with breast, non-small cell lung, prostate, rectal, or endometrial cancer between 1988 and 1999. We used logistic regression analysis, adjusted for age, stage and period of diagnosis. Medium-sized and small hospitals referred breast cancer patients more often (OR = 2.2, 95%CI: 2.0–2.5, OR = 1.2, 95%CI: 1.1–1.4, respectively), and patients with prostate cancer less often (OR = 0.7 (0.5–0.8) and 0.7 (0.6–0.9), respectively). Referral rates for patients with non-small cell lung and rectal cancer showed minor differences according to hospital size, referral for endometrial cancer was somewhat higher for patients from medium-sized hospitals (OR = 1.5 (1.0–2.1)). Time trends in variation were shown, but differences according to hospital size only decreased over time for rectal cancer. Despite multidisciplinary oncology meetings and treatment guidelines there were large variations in rates of referral for radiotherapy.

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^☆: This work was supported by grant HS 08397 from the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) to the Patient Outcomes Research Team for Prostatic Diseases. Dr. McNaughton Collins is a recipient of a Doris Duke Clinical Scientist Award.

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Adult urologyUnited States radiation oncologists’ and urologists’ opinions about screening and treatment of prostate cancer vary by region☆

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Survey respondent characteristics

Comment

Conclusions

J Urol

Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer

JAMA

Small area variations in health care delivery

Science

Variations in medical care among small areas

Sci Am

Variations in the use of medical and surgical services by the Medicare population

N Engl J Med

Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures

JAMA

Hospital use and mortality among Medicare beneficiaries in Boston and New Haven

N Engl J Med

The Dartmouth Atlas of Health Care in the United States

Geographic variation in expenditures for physicians’ services in the United States

N Engl J Med

Adult urology
United States radiation oncologists’ and urologists’ opinions about screening and treatment of prostate cancer vary by region☆