If you visit a Chevy dealer to buy a new car, the odds are pretty good that he is not going to recommend that you purchase a Ford. And he is even more likely not to recommend that you hang on to the perfectly good car you already own. Perhaps not surprisingly, the situation is very similar when men visit physicians who treat localized prostate cancer: Surgeons are more likely to recommend surgery, and radiation specialists will call for X-rays or proton beams, researchers reported Monday in the Archives of Internal Medicine. Only if a man visits a disinterested primary-care physician is he more likely to be offered the alternative that some experts consider optimal -- no treatment at all until the tumor has begun to progress into a more life-threatening form, a concept known as watchful waiting.
The situation may arise, at least in part, because there is such a smorgasbord of potential treatments available, including surgery, radiation, chemotherapy and watchful waiting. If a man chooses surgery, it can be performed by conventional surgery, laparoscopically or with the assistance of a robot. If radiation, it can be delivered conventionally, with proton beams, or by implantation of radioactive seeds, an approach called brachytherapy. What makes the decision even harder, Dr. Michael J. Barry of the Foundation for Informed Medical Decision Making in Boston wrote in an editorial accompanying the report, is that there is an "embarrassing" absence of clinical trials comparing the therapies. The only trial for men over 65, in fact, found that surgical removal of the tumor was no more likely to improve survival than watchful waiting. The National Cancer Institute is now sponsoring a trial to compare treatment to monitoring, but results are not expected until later this year. Until those results are available, however, men rely on their physicians to help them make a decision, and those decisions, framed by anecdotal experience, are likely to be biased.
A 1988 survey of radiation oncologists and urologists -- who perform most prostate surgeries -- asked them which treatment they would prefer if they developed localized prostate cancer. A full 92% of radiation oncologists said they would prefer radiation, while 79% of urologists would opt for a radical prostatectomy. In a 2000 survey, researchers asked the two groups how they would prefer to treat patients, and the results were very similar.
To determine if the doctors' actions jibed with their words, Dr. Thomas L. Jang, now at the Cancer Institute of New Jersey in New Brunswick, and his colleagues used data from the government's Surveillance, Epidemiology and End Results (SEER) database to study 85,088 men over the age of 65 who were diagnosed with localized prostate cancer. Half were seen only by urologists, 44% by urologists and radiation oncologists, 3% by urologists and medical oncologists and 3% by all three groups. Only 22% of the men visited a primary-care physician during the period between diagnosis and treatment, and only 17% visited one they had an established relationship with.
Among men ages 65 to 69, 70% of men who saw only a urologist had a radical prostatectomy. If they also saw a radiation oncologist, however, 78% had radiation therapy. Among men who saw a urologist and a medical oncologist, 53% had surgery, 17% had radiation therapy, 16% had watchful waiting and 14% had chemotherapy--androgen-deprivation therapy to starve the tumor of needed hormones. Men who also visited a primary-care physician were more likely to be prescribed watchful waiting, which is the only one of the treatment regimens without side effects. Older men were also more likely to be prescribed watchful waiting, reflecting a growing adherence to treatment guidelines that recommend against aggressive therapy in men who may have less than 10 years to live.
Part of the reason for the emphasis on treatment, Barry said, is the large capital investments surgeons make for robotically assisted surgery and that radiation therapists make for proton beam therapy or newer techniques of radiation therapy. Moreover, current reimbursement rules do not allow physicians adequate time to educate patients about the pros and cons of the various procedures.
So, if you are diagnosed with prostate cancer and considering therapy, the recommendation is to do the same kind of background research you might do in buying a car. Consider all the options, decide which side effects you are prepared to live with or, in the final analysis, think about whether you really need it in the first place.
-- Thomas H. Maugh II