Urologist experience may influence surveillance choice

Urologists with higher surgical volumes, especially in robotic procedures, are more likely to recommend immediate treatment than active surveillance in men with low-risk prostate cancer, according to a recent study.

Los Angeles-"The decision to initiate an [active surveillance] protocol is complex and dependent on multiple patient and provider factors."

That statement, taken from the introduction to a recent study from researchers at Kaiser Permanente Los Angeles Medical Center, Los Angeles, sums up the issues surrounding the implementation of active surveillance (AS) in men with low-risk prostate cancer.

Physician experience appears to be one of those factors. The study found that urologists with higher surgical volumes, especially in robotic procedures, are more likely to recommend immediate treatment (IT) than AS. The study also found that urologists with fellowship training in oncology and/or robotics are less likely to advise patients to undergo intervention and more likely to recommend AS.

Experience was not a subtle influence; the authors found that surgeons with 50 or more robotic procedures were seven times more likely to recommend IT.

A ‘surprising’ finding

"We looked at many different factors, but the only things that jumped out were experience and training. One of the surprising findings was that surgeons on fellowships receiving training in oncology and robotics were less likely to recommend IT," first author Gary W. Chien, MD, urology program residency director at Kaiser Permanente Los Angeles Medical Center, told Urology Times.

Dr. Chien had no definitive data showing why physicians with additional training in oncology and robotics were less likely to counsel for intervention.

"What we think is that it may be a referral bias in that these doctors are seeing patients who are more complex, and doctors with additional training are likely to be more stringent in selecting patients to operate on," he said. "The take-home message is that we cannot assume that patient clinical pathologic factors are the driving influence in treating a patient under active surveillance for low-risk prostate cancer.”

Although confined to Kaiser Permanente physicians on the West Coast, the study was nevertheless broad based. Some 713 patients managed by 87 urologists were enrolled in the study. Patients had cT1-T2a stage prostate cancer, PSA <10.0 ng/mL, Gleason ≤6, <3 positive biopsy cores, and ≤50% cancer per core. Respondents were all based in Southern California. All other demographics and baseline characteristics were similar.

"We think that one of the strengths of the study is the setting. It is a managed care setting, so every patient has equal access to health care and sees the physician they wish to. In addition, the physicians are salaried so there is no financial incentive influencing their decisions," said Dr. Chien.

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Urologist age, time in practice not factors

Factors such as urologist age and years in practice were examined but did not achieve statistical relevancy.

"What I would like to know is exactly what kind of counseling is going on in consultations. Who is making the decisions? Is it the physician? Is it the patient?" Dr. Chien asked.

He said he would like to see a prospective study that focused on the content and dynamics of counseling sessions, which would identify the actions that influence patient decisions to pursue or reject active surveillance.

The current study, presented at the 2014 World Congress of Endourology and SWL in Taipei, Taiwan, appears to add one more factor to the list of factors that seem to influence decision-making in the face of low-stage prostate cancer.

In June 2014, Urology Timesreported on a survey of 717 U.S. urologists' and radiation oncologists' attitudes toward active surveillance. That survey, published in Medical Care (2014; 52:579-85), was conducted by 13 of the nation's leading urologists, who concluded: "Most prostate cancer specialists in the United States believe AS is effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver."

Urology Times also reported on a study presented at the 2012 American Society of Clinical Oncology annual meeting in Chicago that found that while nearly 75% of radiation oncologists and urologists responding to a survey said that AS was effective, only 16% of oncologists and 28% of urologists would actually choose AS in an appropriately representative case.

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