Letters COMMENT & RESPONSE
Watchful Waiting–Active Surveillance in Low-Risk Prostate Cancer To the Editor As the world’s leading radiation oncology society, we are sensitive to the judicious use of radiation therapy. The conclusions of Chamie et al1 in their recent article regarding the underuse of watchful waiting–active surveillance (WW-AS) for patients with low-risk prostate cancer raise several concerns. Specifically: 1. During the period of the analysis, 2004 to 2007, WW-AS was not widely accepted nor was it the standard of care. There have been significant shifts in our evidence-based understanding of low-risk prostate cancer since 2004, which generated new National Comprehensive Cancer Network treatment guidelines in 2010.2 In 2013, the American Society for Radiation Oncology issued a “Choosing Wisely” recommendation: “Don’t initiate management of low-risk prostate cancer without discussing active surveillance.”3 2. Newly published studies using recent data contradict the findings of Chamie et al1: Weiner et al4 found that among patients with low-risk prostate cancer treated from 2004 to 2010, WW-AS increased from 21% to 32% among Surveillance, Epidemiology, and End Results database patients and from 13% to 20% among National Cancer Data Base patients. Tward et al5 found that radiation therapy declined from 34% of patients in 2004 to 28% of patients in 2011. 3. Chamie et al1 acknowledge the possible influence of selfreferral in increased rates of radiation therapy for prostate cancer patients. An analysis by Mitchell6 of Medicare claims from 2005 through 2010 documented an increase in the use of intensitymodulated radiation therapy by self-referring urologists. A report of the Government Accountability Office7 details a 356% increase in intensity-modulated radiation therapy treatments from 2006 through 2010 and directly attributed the increase to self-referral. The American Society for Radiation Oncology is working to close the loophole in the self-referral law to protect patients and to reduce unnecessary spending.
jamaoncology.com
The American Society for Radiation Oncology encourages multidisciplinary care, whereby the oncology care team provides recommendations regarding multiple treatment options for each patient. Prostate cancer is a complicated disease, and treatment should be in the best interest of each patient. Bruce G. Haffty, MD Colleen A. F. Lawton, MD Howard Sandler, MD, MS Author Affiliations: American Society for Radiation Oncology, Fairfax, Virginia (Haffty, Lawton); Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers–Robert Wood Johnson Medical School, New Brunswick (Haffty); Department of Radiation Oncology, Froedtert and Medical College Clinical Cancer Center, Milwaukee (Lawton); Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California (Sandler). Corresponding Author: Bruce G. Haffty, MD, Rutgers, Cancer Institute of New Jersey, Radiation Oncology, 195 Little Albany St, Room 2012, New Brunswick, NJ 08903 ([email protected]). Published Online: June 4, 2015. doi:10.1001/jamaoncol.2015.1214. Conflict of Interest Disclosures: None reported. 1. Chamie K, Williams SB, Hu JC. Population-based assessment of determining treatments for prostate cancer [published online February 19, 2015]. JAMA Oncol. doi:10.1001/jamaoncol.2014.192. 2. Mohler J, Bahnson RR, Boston B, et al. NCCN clinical practice guidelines in oncology: prostate cancer. J Natl Compr Canc Netw. 2010;8(2):162-200. 3. American Society for Radiation Oncology. Five Things Physicians and Patients Should Question. Choosing Wisely website. http://www.choosingwisely .org/wp-content/uploads/2015/02/ASTRO-Choosing-Wisely-List.pdf. Accessed March 10, 2015. 4. Weiner AB, Patel SG, Etzioni R, Eggener SE. National trends in the management of low and intermediate risk prostate cancer in the United States. J Urol. 2015;193(1):95-102. 5. Tward J, Burt L, Shrieve D. Definitive treatment of localized prostate cancer: time and geographic trends—2015 Genitourinary Cancers Symposium. J Clin Oncol. 2015;33(suppl 7):abstr 132. 6. Mitchell J. Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med. 2013; 369:1629-1637. 7. Report to congressional requesters: Medicare: higher use of costly prostate cancer treatment by providers who self-refer warrants scrutiny. Washington, DC: United States Government Accountability Office (GAO); 2013. GAO 13-525. http://www.gao.gov/assets/660/656026.pdf. Accessed April 30, 2015.
(Reprinted) JAMA Oncology Published online June 4, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
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Watchful Waiting–Active Surveillance in Low-Risk Prostate Cancer To the Editor As the world’s leading radiation oncology society, we are sensitive to the judicious use of radiation therapy. The conclusions of Chamie et al1 in their recent article regarding the underuse of watchful waiting–active surveillance (WW-AS) for patients with low-risk prostate cancer raise several concerns. Specifically: 1. During the period of the analysis, 2004 to 2007, WW-AS was not widely accepted nor was it the standard of care. There have been significant shifts in our evidence-based understanding of low-risk prostate cancer since 2004, which generated new National Comprehensive Cancer Network treatment guidelines in 2010.2 In 2013, the American Society for Radiation Oncology issued a “Choosing Wisely” recommendation: “Don’t initiate management of low-risk prostate cancer without discussing active surveillance.”3 2. Newly published studies using recent data contradict the findings of Chamie et al1: Weiner et al4 found that among patients with low-risk prostate cancer treated from 2004 to 2010, WW-AS increased from 21% to 32% among Surveillance, Epidemiology, and End Results database patients and from 13% to 20% among National Cancer Data Base patients. Tward et al5 found that radiation therapy declined from 34% of patients in 2004 to 28% of patients in 2011. 3. Chamie et al1 acknowledge the possible influence of selfreferral in increased rates of radiation therapy for prostate cancer patients. An analysis by Mitchell6 of Medicare claims from 2005 through 2010 documented an increase in the use of intensitymodulated radiation therapy by self-referring urologists. A report of the Government Accountability Office7 details a 356% increase in intensity-modulated radiation therapy treatments from 2006 through 2010 and directly attributed the increase to self-referral. The American Society for Radiation Oncology is working to close the loophole in the self-referral law to protect patients and to reduce unnecessary spending.
jamaoncology.com
The American Society for Radiation Oncology encourages multidisciplinary care, whereby the oncology care team provides recommendations regarding multiple treatment options for each patient. Prostate cancer is a complicated disease, and treatment should be in the best interest of each patient. Bruce G. Haffty, MD Colleen A. F. Lawton, MD Howard Sandler, MD, MS Author Affiliations: American Society for Radiation Oncology, Fairfax, Virginia (Haffty, Lawton); Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers–Robert Wood Johnson Medical School, New Brunswick (Haffty); Department of Radiation Oncology, Froedtert and Medical College Clinical Cancer Center, Milwaukee (Lawton); Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California (Sandler). Corresponding Author: Bruce G. Haffty, MD, Rutgers, Cancer Institute of New Jersey, Radiation Oncology, 195 Little Albany St, Room 2012, New Brunswick, NJ 08903 ([email protected]). Published Online: June 4, 2015. doi:10.1001/jamaoncol.2015.1214. Conflict of Interest Disclosures: None reported. 1. Chamie K, Williams SB, Hu JC. Population-based assessment of determining treatments for prostate cancer [published online February 19, 2015]. JAMA Oncol. doi:10.1001/jamaoncol.2014.192. 2. Mohler J, Bahnson RR, Boston B, et al. NCCN clinical practice guidelines in oncology: prostate cancer. J Natl Compr Canc Netw. 2010;8(2):162-200. 3. American Society for Radiation Oncology. Five Things Physicians and Patients Should Question. Choosing Wisely website. http://www.choosingwisely .org/wp-content/uploads/2015/02/ASTRO-Choosing-Wisely-List.pdf. Accessed March 10, 2015. 4. Weiner AB, Patel SG, Etzioni R, Eggener SE. National trends in the management of low and intermediate risk prostate cancer in the United States. J Urol. 2015;193(1):95-102. 5. Tward J, Burt L, Shrieve D. Definitive treatment of localized prostate cancer: time and geographic trends—2015 Genitourinary Cancers Symposium. J Clin Oncol. 2015;33(suppl 7):abstr 132. 6. Mitchell J. Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med. 2013; 369:1629-1637. 7. Report to congressional requesters: Medicare: higher use of costly prostate cancer treatment by providers who self-refer warrants scrutiny. Washington, DC: United States Government Accountability Office (GAO); 2013. GAO 13-525. http://www.gao.gov/assets/660/656026.pdf. Accessed April 30, 2015.
(Reprinted) JAMA Oncology Published online June 4, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a University of British Columbia Library User on 06/18/2015
E1
