Determinants of the combined use of external beam radiation therapy and brachytherapy for low-risk localized prostate cancer

Research Objective:

Prostate cancer treatment patterns have been shown to vary by physician and patient characteristics. For patients with low-risk localized prostate cancer, we examined the association between their region of residence and their radiation oncologists' practice affiliations with medical schools on the likelihood they would receive both external beam radiation therapy (EBRT) and brachytherapy (BT) – a treatment regimen that is at variance with clinical guidelines and has not been shown to improve survival or other patient centered outcomes.

Study Design:

Multilevel regression analyses were used to evaluate the influence of patients' region of residence and radiation oncologists' practice affiliations with medical schools on the combined use of EBRT and BT on patients within 6 months of diagnosis.

Population Studied:

Using the Surveillance, Epidemiology and End Results – Medicare linked database and the American Medical Association Physician Masterfile, we conducted a retrospective cohort study of 4,479 patients aged 66 years or older who were diagnosed between 2004 and 2007 with low-risk localized prostate cancer, and the 401 radiation oncologists who saw them.

Principal Findings:

Overall, 231 (5.2%) patients received combined EBRT and BT. After adjusting for patient, tumor and radiation oncologist characteristics, patients who saw radiation oncologists with no practice affiliation with medical schools were significantly more likely to receive combined EBRT and BT (odds ratio [OR], 3.14; 95% confidence interval [95% CI], 1.50-6.59, p=0.003). In addition, regional variations were observed; the odds of receiving combined therapy for patients residing in California (OR, 0.1; 95% CI, 0.03-0.33, p<0.0001) were significantly less than those residing in Georgia (OR, 1.0; referent).

Conclusions:

Low-risk localized prostate cancer patients residing in Georgia were significantly more likely to receive combined EBRT and BT when compared to patients in other SEER Regions. Radiation oncologists without practice affiliations with medical schools were significantly more likely to treat patients with combined EBRT and BT; such treatment patterns are not consistent with patient-centered clinical guidelines and unlikely to have significant survival benefit.

Implications for Policy and Practice:

In addition to increased health care spending, patients who receive combined radiation therapy for localized prostate cancer have been previously shown to suffer from a worse overall quality-of-life compared to those not receiving this combined treatment. The significant associations found in this study provide additional evidence for clinicians and policy makers regarding areas to target to reduce the overtreatment of low-risk localized prostate cancer patients and increase adherence to evidence-based guidelines.