The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, August 26, 2014

First, find a Doctor You Like . . .


A urologist I consulted in Hawaii, a man with a big reputation, told me to go home and settle my affairs, because I was going to die. That was 16 years ago.

When your are visiting a doctor, his reputation shouldn’t matter.  Even if he’s a great urologist or a world class prostate oncologist, If he makes you uncomfortable, dump him!  Never mind why.  This is your life. Find yourself another doctor.

Nor is this simply a matter of learning to be comfortable with personality differences. There is also a purely practical side to this— studies show that personality influences treatment selection.  “The physician a patient sees can influence their treatment fate,” according Dr. Karen Hoffman, lead author of a recent study from the University of Texas MD Anderson Cancer Center in Houston. “Physicians play an important role in whether or not men with low-risk prostate cancer are managed with observation or treatment.”

According to a new study, whether a man’s low-risk prostate cancer gets treated with surveillance, surgery or another form of radical treatment, may have more to do with his doctor than that man’s health status.   For example, the study found that urologists who have been practicing for more years or had more patients with advanced disease were less likely to use a wait-and-see approach to manage low-risk prostate cancer.

The issue of how physicians steer patients toward one treatment or away from another has become a major national health issue since prostate cancer is so common, occurring in over 200,000 men annually.  Dr. Hoffman and her colleagues write in JAMA Internal Medicine that most common type of prostate cancer, the low-risk variety, is not likely to affect how long men live even without treatment and  radical treatment  can lead to complications like rectal bleeding, impotence and problems with bladder control.

Good medicine dictates that the treatment a patient receives is supposed to be dependent on factors such as their age, health status and the stage of their disease.  Dr. Hoffman’s study euphemistically described as “doctor characteristics” as the main force driving treatment decisions. The study analyzed data from 12,068 men ages 66 years and older who were diagnosed with low-risk prostate cancer by 2,145 urologists between 2006 and 2009.

Only about a fifth of the men had their prostate cancer managed with active surveillance. The rest received up-front treatment, such as surgery or radiation.

The proportion of patients that each doctor put on active surveillance varied from less than five percent to about 64 percent.

The researchers found that doctor characteristics were twice as important as patient characteristics, such as age and other conditions, in predicting whether a patient would receive active surveillance or up-front treatment. “The rate of treatment of older men with low-risk disease is well documented to be extremely high,” said Dr. H. Ballentine Carter, professor of urology and oncology at Johns Hopkins Medicine in Baltimore “I think we need to do a better job of educating older individuals with low-risk disease.”

According to Ballantine, we are asking the wrong questions. The question should not be which treatment men need but whether they need any treatment at all.

One option for reducing potentially unnecessary treatment is to make public the track records of doctors who consistently advise radical treatment so primary care doctors would know that information before they referred their patients.

Dr. Hoffman pointed out that doctors would also want to base their decision on other measures, such as potential complications after treatment, age, and follow-up care, because active surveillance is not always the best treatment option.

Bottom line, patients need to feel good about their physician. And equally important, they must become more proactive regarding the big question: To treat or not to treat?

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