Physician variation in management of low-risk prostate cancer: A population-based cohort study

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.