Prostate cancer management varies at academic, private hospitals

February 1, 2010

A study designed to compare prostate cancer treatment modalities between academic centers and private hospitals reveals significant disparities between the two practice settings.

Key Points

The project represents an effort led by Robert E. Weiss, MD, of Robert Wood Johnson Medical Center, New Brunswick, NJ, with collaboration from Robert S. DiPaola, MD, of the Cancer Institute of New Jersey (CINJ). The study population was comprised of 2,545 consecutive newly diagnosed patients seen from January 2003 to December 2004 within the CINJ Affiliate Network, which includes three academic centers (575 patients) and 12 private hospitals (1,970 patients).

The analysis showed that surgical volume accounted for a significantly higher proportion of management at academic centers compared with private hospitals (45% vs. 31.5%), whereas private hospitals had significantly higher rates of brachytherapy (18.5% vs. 4.5%) and external beam radiation (XRT, 26% vs. 21%).

While a December 2006 New York Times article suggested that intensity-modulated radiation therapy (IMRT) was becoming the treatment of choice for an increasing number of private practice groups-a trend that was perhaps motivated more by money than medicine-within the CINJ population, rates of IMRT were similarly low among the private practice and academic institutions.

"We believe ours is the first study to investigate differences in approaches to prostate cancer treatment and patient population characteristics between academic centers and private hospitals," said Philip T. Zhao, MD, a urology resident at Robert Wood Johnson Medical Center, who presented the findings. "It is likely that patient selectivity, physician referral patterns, technical availability, and reimbursement rates all contribute to choice of treatment and the differences noted in our study."

However, he noted several caveats for considering the data.

"Our findings are specific to New Jersey and reflect practice patterns from several years ago. We likely could not capture enough data points to paint an adequate picture of the extent of use of IMRT while recent data indicate an increasing number of private practice groups are purchasing IMRT systems. In addition, the paradigm has been changed by the advent of robotic prostatectomy and decreased reimbursement for surgery," Dr. Zhao explained.

"Therefore, we consider our study as a good starting point, but see a need for updating the data and expanding the research to the national level."

The data on treatment approaches were also analyzed, looking only at men with low-risk, organ-confined disease who were defined as age 75 years or less, Gleason score ≤6, cT stage ≤2, and PSA ≤10.0 ng/mL. For this population, comprised of 181 men from academic centers and 751 treated at private hospitals, the rate of radical prostatectomy was still significantly higher at academic centers than private hospitals, while the discrepancy in use of brachytherapy widened, and XRT rates were the same for the two practice settings.

"Brachytherapy is estimated to cost about 2 to 2.5 times more than RP, but its cost effectiveness has not yet been established," Dr. Zhao noted.

Sociodemographic factors differ

Additional analyses showed differences in the sociodemographic characteristics of the two patient populations and the approach to diagnosis. The private hospitals had an older patient population than the academic centers (age >70 years, 42% vs. 26%), a higher proportion of Caucasians (86% vs. 65%), and diagnosed prostate cancer by biopsy more often (93% vs. 79%).

There were no significant differences between the populations from the two settings with respect to distribution of Gleason score and clinical and pathologic stages, although the academic centers saw more men with Gleason 8-9 disease and a higher proportion with cT4 disease.