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Original Investigation |

Physician Variation in Management of Low-Risk Prostate Cancer:  A Population-Based Cohort Study

Karen E. Hoffman, MD, MHSc, MPH1; Jiangong Niu, PhD2; Yu Shen, PhD3; Jing Jiang, PhD3; John W. Davis, MD4; Jeri Kim, MD5; Deborah A. Kuban, MD1; George H. Perkins, MD1; Jay B. Shah, MD3; Grace L. Smith, MD, PhD, MPH1; Robert J. Volk, PhD6; Thomas A. Buchholz, MD1; Sharon H. Giordano, MD, MPH2; Benjamin D. Smith, MD1
[+] Author Affiliations
1Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
2Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
3Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
4Department of Urology, The University of Texas MD Anderson Cancer Center, Houston
5Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
6Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston
JAMA Intern Med. 2014;174(9):1450-1459. doi:10.1001/jamainternmed.2014.3021.
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Importance  Up-front treatment of older men with low-risk prostate cancer can cause morbidity without clear survival benefit; however, most such patients receive treatment instead of observation. The impact of physicians on the management approach is uncertain.

Objective  To determine the impact of physicians on the management of low-risk prostate cancer with up-front treatment vs observation.

Design, Setting, and Participants  Retrospective cohort of men 66 years and older with low-risk prostate cancer diagnosed from 2006 through 2009. Patient and tumor characteristics were obtained from the Surveillance, Epidemiology, and End Results cancer registries. The diagnosing urologist, consulting radiation oncologist, cancer-directed therapy, and comorbid medical conditions were determined from linked Medicare claims. Physician characteristics were obtained from the American Medical Association Physician Masterfile. Mixed-effects models were used to evaluate management variation and factors associated with observation.

Main Outcomes and Measures  No cancer-directed therapy within 12 months of diagnosis (observation).

Results  A total of 2145 urologists diagnosed low-risk prostate cancer in 12 068 men, of whom 80.1% received treatment and 19.9% were observed. The case-adjusted rate of observation varied widely across urologists, ranging from 4.5% to 64.2% of patients. The diagnosing urologist accounted for 16.1% of the variation in up-front treatment vs observation, whereas patient and tumor characteristics accounted for 7.9% of this variation. After adjustment for patient and tumor characteristics, urologists who treat non–low-risk prostate cancer (adjusted odds ratio [aOR], 0.71 [95% CI, 0.55-0.92]; P = .01) and graduated in earlier decades (P = .004) were less likely to manage low-risk disease with observation. Treated patients were more likely to undergo prostatectomy (aOR, 1.71 [95% CI, 1.45-2.01]; P < .001), cryotherapy (aOR, 28.2 [95% CI, 19.5-40.9]; P < .001), brachytherapy (aOR, 3.41 [95% CI, 2.96-3.93]; P < .001), or external-beam radiotherapy (aOR, 1.31 [95% CI, 1.08-1.58]; P = .005) if their urologist billed for that treatment. Case-adjusted rates of observation also varied across consulting radiation oncologists, ranging from 2.2% to 46.8% of patients.

Conclusions and Relevance  Rates of management of low-risk prostate cancer with observation varied widely across urologists and radiation oncologists. Patients whose diagnosis was made by urologists who treated prostate cancer were more likely to receive up-front treatment and, when treated, more likely to receive a treatment that their urologist performed. Public reporting of physicians’ cancer management profiles would enable informed selection of physicians to diagnose and manage prostate cancer.

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Figure 1.
Cohort Selection Criteria

cT Indicates clinical tumor, and PSA, prostate-specific antigen.aThis step excluded patients whose diagnosis was made by transurethral resection of the prostate alone; patients who received a diagnosis in the Veterans Affairs or military medical system, in which claims are not submitted; and patients whose diagnostic biopsy was performed by a nonurologist. There were no clinically meaningful differences between men who were and were not matched to a diagnosing urologist.bThese men were used to determine urologist diagnosis volume and radiation oncologist treatment volume.cThese men who did not have low-risk prostate cancer were used to determine whether or not the urologist treated non–low-risk prostate cancer. dBecause men with cT2NOS disease could have higher-volume disease, men with cT2 disease were excluded from sensitivity analyses.

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Figure 2.
Case-Adjusted Frequency of Management of Low-Risk Prostate Cancer With Observation for Individual Urologists and Radiation Oncologists

Frequency of observation is adjusted for patient age, race and ethnicity, comorbidity, Medicaid coverage, clinical tumor category, and serum prostate-specific antigen level. Red dotted line indicates mean case-adjusted frequency of observation, and black bars, physicians who had rates significantly different from the mean (P < .05). The 95% confidence interval bars take into account variability of the calculated rate based on the size of the patient panel. A, Frequency by rank, from lowest (4.5%) to highest (64.2%), for 391 urologists who diagnosed low-risk prostate cancer in at least 10 men in the study cohort (blue line). Mean case-adjusted frequency was 19.7%; 40 urologists had rates significantly different from the mean. B, Frequency by rank, from lowest (2.2%) to highest (46.8%), for 226 radiation oncologists who saw at least 10 men with low-risk prostate cancer in the study cohort (blue line). Mean case-adjusted frequency of observation was 8.5%; 20 radiation oncologists had rates significantly different from the mean.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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