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From the JAMA Network |

Variation in Prostate Cancer Care

Khurshid R. Ghani, MBChB, MS1; David C. Miller, MD, MPH1
[+] Author Affiliations
1Dow Division of Health Services Research and Department of Urology, University of Michigan, Ann Arbor
JAMA. 2015;313(20):2066-2067. doi:10.1001/jama.2015.0607.
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JAMA Internal Medicine

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

Karen E. Hoffman, MD, MHSc, MPH; Jiangong Niu, PhD; Yu Shen, PhD; Jing Jiang, PhD; John W. Davis, MD; Jeri Kim, MD; Deborah A. Kuban, MD; George H. Perkins, MD; Jay B. Shah, MD; Grace L. Smith, MD, PhD, MPH; Robert J. Volk, PhD; Thomas A. Buchholz, MD; Sharon H. Giordano, MD, MPH; Benjamin D. Smith, MD

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.

JAMA Intern Med. 2014;174(9):1450-1459. doi:10.1001/jamainternmed.2014.3021

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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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