Physician visits prior to treatment for clinically localized prostate cancer

Abstract

Background: The 2 primary therapeutic interventions for localized prostate cancer are delivered by different types of physicians, urologists, and radiation oncologists. We evaluated how visits to specialists and primary care physicians (PCPs) by men with localized prostate cancer are related to treatment choice.

Methods: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we identified 85 088 men with clinically localized prostate cancer diagnosed at age 65 years or older, between 1994 and 2002. Men were categorized by primary treatment received within 9 months of diagnosis: radical prostatectomy (n = 18 201 [21%]), radiotherapy (n = 35 925 [42%]), androgen deprivation (n = 14 021 [17%]), or expectant management (n = 16 941 [20%]). Visits to specialists and PCPs were analyzed by patient characteristics and primary therapies received and were identified using Medicare claims and the American Medical Association Physician Masterfile.

Results: Overall, 42 309 men (50%) were seen exclusively by urologists, 37 540 (44%) by urologists and radiation oncologists, 2329 (3%) by urologists and medical oncologists, and 2910 (3%) by all 3 specialists. There was a strong association between the type of specialist seen and primary therapy received. Visits to PCPs were infrequent between diagnosis and receipt of therapy (22% of patients visited any PCP and 17% visited an established PCP) and were not associated with a greater likelihood of specialist visits. Irrespective of age, comorbidity status, or specialist visits, men seen by PCPs were more likely to be treated expectantly.

Conclusions: Specialist visits relate strongly to prostate cancer treatment choices. In light of these findings, prior evidence that specialists prefer the modality they themselves deliver and the lack of conclusive comparative studies demonstrating superiority of one modality over another, it is essential to ensure that men have access to balanced information before choosing a particular therapy for prostate cancer.

Figure 1

Definition of study cohort of 85,088 men with clinically localized prostate cancer.

Figure 2

Specialists that were consulted prior to definitive treatment for a) 18,201 men who had a radical prostatectomy; b) 35,925 men who had radiation therapy. Note: Missing physician specialty codes on claims for radiotherapy accounted for the 7% of patients who received radiotherapy but for whom a visit with a radiation oncologist could not be identified.

Figure 2

Specialists that were consulted prior to definitive treatment for a) 18,201 men who had a radical prostatectomy; b) 35,925 men who had radiation therapy. Note: Missing physician specialty codes on claims for radiotherapy accounted for the 7% of patients who received radiotherapy but for whom a visit with a radiation oncologist could not be identified.

Figure 3

Observed versus expected distribution of an individual urologist’s patient to undergo a radiation oncologist evaluation.