In a study reported in JCO Oncology Practice, Lai et al found that although the majority of men who have initiated active surveillance for prostate cancer are followed by urologists, some are managed by physicians in other specialties, and that testing and subsequent treatment patterns vary across those specialties.
Study Details
The study included evaluation of data from a 20% national sample of Medicare claims that identified 13,048 men diagnosed with prostate cancer from 2010 through 2016 who initiated active surveillance. Patients were assigned to the physician responsible for the majority of surveillance care based on billing patterns. Freedom from treatment was assessed by specialty of the responsible physician, with specialties consisting of urology, radiation oncology, medical oncology, and primary care.
Key Findings
Overall, urologists were the responsible physician for 94.4% of patients, with 2.0% managed by radiation oncologists, 2.0% by medical oncologists, and 1.6% by primary care physicians. The proportion followed by urologists increased from 93.7% in 2010 to 96.2% in 2016 (P = .01 for trend).
Patients with a comorbidity score ≥ 2 (modified Charlson comorbidity index) were more likely to be managed by medical oncologists (30.7%) and radiation oncologists (28.6%) than by urologists (20.5%; overall P = .01).
Patients followed by medical oncologists had more frequent prostate-specific antigen testing, at 2.39 tests per patient-year; frequency of testing per patient-year in other specialties ranged from 1.71 for primary care physicians to 1.91 for radiation oncologists (overall P < .01).
Patients followed by medical oncologists had more frequent magnetic resonance imaging scans (0.13 per patient-year) compared with those followed by other specialties (range = 0.07–0.08 per patient-year, overall P < .01).
Patients followed by urologists had the greatest frequency of prostate biopsies (0.24 per patient-year), with those followed by radiation oncologists having the lowest rate (0.18 per patient-year; overall P < .01).
At 3 years after diagnosis, 64.3% of patients followed by radiation oncologists remained on surveillance, compared with 75.8% for urologists, 79.1% for medical oncologists, and 79.5% for primary care physicians (overall P < .01).
Radiation therapy was the most common treatment among patients transitioning to treatment, irrespective of specialty. Among those transitioning to treatment, 28.9% of those followed by radiation oncologists received radiation therapy, compared with 15.4% for urologists, 15.1% for medical oncologists, and 15.1% for primary care physicians (P < .01 for each specialty vs radiation oncology).
The investigators concluded, “Nontrivial percentages of patients on active surveillance are managed by physicians outside of urology. Given the interspecialty variations observed, efforts to strengthen the evidence underlying surveillance pathways and to engage other specialties in guideline development are needed.”
Lillian Y. Lai, MD, of the Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, is the corresponding author for the JCO Oncology Practice article.
Disclosure: The study was supported by the Agency for Healthcare Research and Quality and National Cancer Institute. For full disclosures of the study authors, visit ascopubs.org.
