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Urologists and radiation oncologists agree on some aspects of prostate cancer treatment but not on which treatment is best

A new survey of urologists and radiation oncologists sponsored by the Agency for Healthcare Research and Quality (HS08397) reveals that the two groups of specialists largely agree that radical prostate surgery, external beam radiotherapy, and brachytherapy are potentially life-saving treatments for localized prostate cancer in men whose normal life expectancy is 10 years or longer. Radical prostate surgery involves removal of the entire prostate gland and any affected surrounding tissue; external beam radiotherapy shoots X-rays into the tumor from outside the body; and brachytherapy consists of inserting tiny radioactive pellets through a needle into the tumor.

The study also found that almost all the urologists and radiation oncologists agreed that prostate-specific antigen (PSA) testing should be included as part of primary care physicians' routine physical examination of men between 50 and 75 years of age. But the specialists, who treat most of the approximately 180,000 new cases of prostate cancer diagnosed each year, disagreed about which treatments they would recommend to their patients. More than nine of every ten urologists questioned (93 percent) said they considered prostate surgery better than radiation therapy for men with a normal life expectancy of 10 years or more, while 72 percent of the radiation oncologists indicated that they believed radiotherapy worked as well as radical prostatectomy for such men. To date, randomized clinical trials have not proven that aggressive treatment of prostate cancer with either surgery or radiotherapy improves patient outcomes, but neither have they proven that the two therapies are ineffective.

Some patients will find it confusing to hear different treatment recommendations from doctors, notes the study's principal investigator, Michael J. Barry, M.D., of the Medical Practices Evaluation Center at Massachusetts General Hospital. He notes that scheduling consultations with a member of each specialty before making a decision may be the best way to get a balanced view of treatment options.

The researchers also found that:

  • Both groups of physicians generally agreed on the probability of complications from all three therapies and that prostatectomy is more likely than radiotherapy to cause incontinence and sexual dysfunction.
  • Both groups also agreed that nerve-sparing surgery reduces the rate at which patients experience sexual dysfunction.
  • Both groups proved strikingly similar in the extent to which they would recommend either watchful waiting or depriving the cancer of the male hormone androgen as first-line treatment for certain subsets of men. Treatment for these men would be based on their Gleason scores—a scale running from 2 to 10 which indicates the aggressiveness of tumor growth—and their PSA levels.
  • But fewer than 25 percent of physicians in either group said they would recommend watchful waiting to men with unaggressive tumors (Gleason score of 3), despite the fact that such patients appear to have a normal life expectancy without aggressive treatment. About 40 percent would recommend androgen deprivation to men with the most aggressive tumors and highest PSA levels.
  • Despite insufficient data on the long-term effects of brachytherapy, members of both specialties generally thought it is as least as good as external beam radiation. Urologists seemed to be slightly more positive about brachytherapy than external beam radiotherapy.

The study findings are based on answers to questionnaires returned by 559 radiation oncologists (76 percent response rate) and 504 urologists (64 percent response rate) from across the nation. The survey was conducted in 1998 as part of a prostate cancer Patient Outcomes Research Team (PORT) project funded by AHRQ. The analysis was conducted by researchers from the University of Massachusetts, Massachusetts General Hospital, and the University of Connecticut Health Center.

Details are in "Comparison of treatment recommendations by urologists and radiation oncologists for men with clinically localized prostate cancer," in the June 28, 2000 issue of the Journal of the American Medical Association 283(24), pp. 3217-3222.

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