low-risk prostate cancer, ddiscordant specialist recommendations

this article was sent to me by gordy schiff. interesting study of perceptions and suggestions of US radiation oncologists and urologists on the effectiveness of active surveillance for patients with prostate cancer (see prostate cancer active surveillance. medcare2014 or Med Care 2014;52: 579–585). baseline is that there are general concerns that prostate cancer is greatly overtreated, and that active surveillance (AS) is appropriate (and in fact recommended) for low-risk prostate cancer (clinically localized disease, PSA in 4-10 range, Gleason 6 or less). results:

    --national survey of radiation oncologists and urologists about perceptions of AS, done from nov 2011 to april 2012, with 717 completing survey
    --71.9% thought AS effective and 80% thought it was underused
    --BUT for a case patient of a 60yoM  diagnosed with low-risk prostate cancer, these specialists recommended radical prostatectomy in 44.9%, brachytherapy in 35.4% and AS only in 22.1%. though specialists in academic med centers more likely to recommend AS, with OR 2.35.
    --and, lest anyone is surprised, urologists vs radiation oncologists were more likely to recommend surgery (OR of 4.19) and less likely to recommend radiation treatment (OR 0.13 for brachytherapy and OR 0.11 for external beam radiation)

so, 230K patients are diagnosed each year with prostate cancer. and estimated 100K with clinically-localized disease, qualifying for AS. clinical guidelines do recommend AS with close disease monitoring by frequent PSA tests, digital rectal exams and  biopsies; but most patients are treated with XRT or surgery and only 10% get AS. clearly, a key barrier to AS is that the specialists involved in the care of these patients (radiation oncologists, urologists) are in fact more aggressive than the recommendations (and, indeed, more aggressive than what they even said -- that up to 80% thought AS was underused). given their inherent conflicts-of-interest, seems to me that primary care providers (and general oncologists) should be stronger advocates for patients with low-risk prostate cancer.

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