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    Urologist experience may influence surveillance choice

    High-volume surgeons more likely to recommend immediate treatment, data show

    Los Angeles—"The decision to initiate an [active surveillance] protocol is complex and dependent on multiple patient and provider factors."

    That statement, taken from the introduction to a recent study from researchers at Kaiser Permanente Los Angeles Medical Center, Los Angeles, sums up the issues surrounding the implementation of active surveillance (AS) in men with low-risk prostate cancer.

    RELATED: How 'low risk' is low-risk prostate cancer?

    Physician experience appears to be one of those factors. The study found that urologists with higher surgical volumes, especially in robotic procedures, are more likely to recommend immediate treatment (IT) than AS. The study also found that urologists with fellowship training in oncology and/or robotics are less likely to advise patients to undergo intervention and more likely to recommend AS.

    Experience was not a subtle influence; the authors found that surgeons with 50 or more robotic procedures were seven times more likely to recommend IT.

    A ‘surprising’ finding

    "We looked at many different factors, but the only things that jumped out were experience and training. One of the surprising findings was that surgeons on fellowships receiving training in oncology and robotics were less likely to recommend IT," first author Gary W. Chien, MD, urology program residency director at Kaiser Permanente Los Angeles Medical Center, told Urology Times.

    Dr. Chien had no definitive data showing why physicians with additional training in oncology and robotics were less likely to counsel for intervention.

    "What we think is that it may be a referral bias in that these doctors are seeing patients who are more complex, and doctors with additional training are likely to be more stringent in selecting patients to operate on," he said. "The take-home message is that we cannot assume that patient clinical pathologic factors are the driving influence in treating a patient under active surveillance for low-risk prostate cancer.”

    Although confined to Kaiser Permanente physicians on the West Coast, the study was nevertheless broad based. Some 713 patients managed by 87 urologists were enrolled in the study. Patients had cT1-T2a stage prostate cancer, PSA <10.0 ng/mL, Gleason ≤6, <3 positive biopsy cores, and ≤50% cancer per core. Respondents were all based in Southern California. All other demographics and baseline characteristics were similar.

    "We think that one of the strengths of the study is the setting. It is a managed care setting, so every patient has equal access to health care and sees the physician they wish to. In addition, the physicians are salaried so there is no financial incentive influencing their decisions," said Dr. Chien.

    Next: Urologist age, time in practice not factors

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