Prostate Cancer Physicians Agree Active Surveillance is Underused, But Still Recommend More Aggressive Primary Treatments

Radiation oncologists and urologists surveyed indicate the primary treatment provided by the other specialty is being overused.

Radiation oncologists and urologists are on the same page regarding the underuse of active surveillance [AS] in the treatment of prostate cancer, but physicians in both specialties tend to recommend other primary treatments to patients.

In a study published in the July 2014 edition of Medical Care, a random sample of radiation oncologists and urologists were surveyed to assess perceptions regarding care patterns in the treatment of localized prostate cancer. Despite a majority of physicians indicating that AS is an effective and underused treatment option and that primary therapies for localized prostate cancer are overused, physicians reported that a high number of patients were not interested in AS.

“Current perceptions of radiation oncologists and urologists on whether AS is effective and the degree to which it is recommended may represent key barriers to its greater adoption in clinical practice,” the study authors wrote. “Attitudes toward this conservative disease management approach from specialists who treat prostate cancer may contextualize the relatively low adoption of AS in the United States.”

The study finds that approximately 100,000 patients are eligible for AS each year, however, only 10% of patients undergo this treatment option. Researchers note a majority of low-risk prostate cancer patients with multiple comorbidities are overtreated with brachytherapy, radiation therapy, or surgery. The study finds that intensity-modulated radiation therapy and robotic surgery are frequently utilized for patients with low-risk prostate cancer or limited life expectancy who are least likely to benefit from the treatment.

Of the 717 radiation oncologists and urologists who responded to the survey, 71.9% indicated that AS was effective and 68.6% said they feel comfortable recommending it as a disease management strategy.

“Despite a majority of physicians viewing AS as effective and underused, radiation oncologists and urologists consistently selected brachytherapy or surgery from the case presentation inquiring for treatment recommendations of a 60-year-old man diagnosed with low-risk prostate cancer,” the authors wrote.

The study found that urologists were more likely than radiation oncologists to agree that AS is effective (75.5% vs 65.7%) and were comfortable recommending it (75.8% vs 61.7%) for low-risk prostate cancer patients.

Approximately 80% of physicians from each specialty indicated that AS is underused. About 70% of radiation oncologists stated that radical prostatectomy is overused, while a higher proportion of urologists said brachytherapy (37.1% vs 17.8%) and external beam radiation therapy (48.2% vs 32.4%) are overused compared with radiation oncologists.

In total, the survey found two-thirds of urologists recommend surgery, and half of radiation oncologists chose brachytherapy or radiation therapy, while 22.1% of physicians chose AS for primary treatment of low-risk prostate cancer.

“In our study, most radiation oncologists and urologists were concerned about overtreatment with radical prostatectomy and radiation therapy, but their perceptions of what treatments were the culprit in overtreatment varied by physician specialty,” the authors wrote. “In this regard, radiation oncologists and urologists concluded that primary treatment provided by the other specialty as being overused.”

Of physicians, 71% said their patients were not interested in AS as a disease management strategy. Due to the majority of treatment recommendations favoring radiation therapy and surgery, the researchers conclude that the role of AS can be improved by enhancing the clinical encounter between patients and physicians at the time of diagnosis by explaining the evidence-based benefits for improved survival and quality of life issues.

“Therefore, increased attention is needed to ensure that patient preferences are incorporated into treatment decisions and decision aids and tools are more easily implemented into clinical practice,” the authors wrote. “By doing so, AS may then become a more acceptable disease management strategy for low-risk prostate cancer among newly diagnosed patients and specialists.”