Specialty may bias doctors' prostate cancer advice

NEW YORK (Reuters Health) - New research suggests that the type of specialist a prostate cancer patient sees -- rather than the patient’s own preference -- may determine the treatment he receives.

This is problematic, the study’s authors say, because none of the options now available for treating localized prostate cancer have been shown to be any better than the others.

“The different treatments for prostate cancer...entail different side effects, different recovery profiles, and they require different time commitments,” Dr. Thomas L. Jang of The Cancer Institute of New Jersey in New Brunswick, one of the study’s authors, told Reuters Health. For this reason, he and his colleagues say, it should be the patient’s preferences -- rather than the physician’s specialty -- that guides treatment decisions.

Current options available for treating prostate cancer that has not spread include watchful waiting, in which a patient receives no treatment but is monitored closely; hormone therapy; radiation therapy; or surgery to remove the prostate. Radiation and surgery both carry the risk of urinary incontinence and impotence; hormone therapy can cause hot flashes, breast tenderness, and loss of sex drive; while watchful waiting may lead to anxiety in men who fear their cancer will spread.

Surveys have suggested that specialists are more likely to recommend the type of treatment they provide; for example, radiation oncologists prefer radiation therapy, while urologists choose surgery.

To investigate whether the type of physician a prostate cancer saw would actually influence the type of treatment he got, Jang and his team looked at Medicare data on more than 85,000 men 65 and older diagnosed between 1994 and 2002 with localized prostate cancer. Within nine months of diagnosis, 21 percent had undergone prostate removal; 42 percent had radiation; 17 percent had hormone therapy; and 20 percent watchful waiting. Jang conducted the study, which is published in the Archives of Internal Medicine, while at Memorial-Sloan Kettering Cancer Center in New York City.

Half of the men had only seen a urologist, while 44 percent had seen a radiation oncologist and a urologist, 3 percent had seen a urologist and a medical oncologist, and 3 percent had seen all three specialists.

One-third of the men who had only seen a urologist underwent prostate surgery, and surgery was the most common treatment for the men who were 65 to 74 years old and only saw a urologist. However, among men of any age who saw a radiation oncologist as well as a urologist, radiation therapy was the most common treatment; 83 percent of these men received radiation therapy.

And men who had been seen by a urologist and a medical oncologist, or a urologist only, were more likely to receive watchful waiting or hormone therapy than men who had seen both urologists and radiation oncologists.

Only about one in five men saw their primary care physician after their diagnosis of prostate cancer and before they received treatment (or within nine months of diagnosis). Nearly 60 percent of these men received watchful waiting, compared to 7 percent of men who hadn’t seen their primary care doctor.

When the researchers looked at individual urologists who had cared for at least 10 of the study participants, they found sharp doctor-to-doctor differences in whether a patient was referred to a radiation oncologists; some urologists frequently made these referrals, while others did so much less often.

Men newly diagnosed with prostate cancer face “a lot of confusion,” Jang noted, because there are so many treatment options available. “The physician who is providing the counseling for these patients should go to great lengths to provide a balanced perspective, an unbiased perspective, on these treatment options.”

And if patients don’t feel they are getting unbiased advice, Jang added, they should get a second opinion. “It’s really our responsibility to provide these men with every single available treatment option.”

SOURCE: Archives of Internal Medicine, March 8, 2010.