We represent 23 of our nation’s leading cancer hospitals on the National Comprehensive Cancer Network (NCCN) Prostate Cancer Guidelines Panel and, as the Panel Chair, I speak on behalf of NCCN. We volunteer our time and knowledge to improve the quality, effectiveness, and efficiency of care provided to men with prostate cancer. Therefore, we are concerned unanimously by the prostate cancer treatment patterns identified in the [October 23, 2013] article titled, “Urologists Use of Intensity Modulated Radiation Therapy (IMRT) for Prostate Cancer,” published in the New England Journal of Medicine. We are disappointed to learn that urologists who self-refer for IMRT services use this expensive technology more than urologists who don’t self-refer and more than the NCCN Member Institutions.
The NCCN Clinical Practice Guidelines on Oncology (NCCN Guidelines) for Prostate Cancer provides a framework for early detection, evaluation, treatment, and follow-up to help urologists, radiation oncologists, and medical oncologists, who partner with men, their primary care physicians, and their loved ones, to “right-size” treatment. Use of these Guidelines promotes the delivery of high-quality care. Most men with prostate cancer as classified by NCCN as “very low” risk and many men with “low” risk cancer are best served by careful “active surveillance.” Active surveillance seeks to deliver treatment only to those men who require it while avoiding the side effects of operation or radiation that was not necessary in the first place. The NCCN Prostate Cancer Guidelines Panel remains committed to providing men and their physicians with the best possible guidance so they can make the best choices for management of this all-too-common cancer.
[The October 23] study supports 1) the report by the Government Accountability Office on self-referral, which provided evidence of overtreatment of prostate cancer resulting, at least in part, from the Stark Law In-Office Exception, commonly known as the physician self-referral loophole; and 2) the letter in The Journal of the American Medical Association (JAMA) published 2 weeks ago that reported that less than 4% of men who underwent radiation for bone metastases had a single session treatment, which is less expensive, more convenient, equally efficacious, and recommended by NCCN based on the results of 7 clinical trials.
Prostate cancer complexity is evidenced by some simple facts and their implications:
Approximately 70% of 70-year-old American men have prostate cancer, so most cases are not diagnosed and not threatening to life;
1 in 6 American men will be diagnosed with prostate cancer, so many men are confronted with decision-making based on imperfect information;
1 in 40 American men will die of prostate cancer, so earlier detection and treatment have not eliminated prostate cancer mortality;
Aggressive prostate cancer diagnosis and treatment have reduced prostate cancer mortality by about 40%, so treatment, when necessary, is beneficial;
Treatment has side effects of urinary incontinence and impotence, and these side effects occur all too commonly after either operation or radiation; and
Many men (best estimates range from 40% to 50%) with prostate cancer do not need treatment because they have low-volume, slow-growing cancers that are unlikely to cause health problems during their lifetimes.
Right-sizing prostate cancer treatment is a tremendous challenge. NCCN recommendations are based on high-level evidence when available, indicate when lesser levels of evidence create uncertainty, and encourage clinical trial participation to enhance knowledge. The use of NCCN Guidelines facilitates the delivery of high-quality care and minimizes the risk of overtreatment or undertreatment. Men should be educated and counseled about all appropriate treatment options outlined in evidenced-based guidelines so they can make the choice they feel is best for them. Prostate cancer treatment recommendations should be based on the best available clinical evidence and not influenced by business or personal interests of the care provider.
James L. Mohler, MD; Philip W. Kantoff, MD; Andrew J. Armstrong, MD, ScM; Robert R. Bahnson, MD; Michael Cohen, MD; Anthony Victor D’Amico, MD, PhD; James A. Eastham, MD; Charles A. Enke, MD; Thomas A. Farrington, BSEE; Celestia S. Higano, MD, FACP; Eric Mark Horwitz, MD; Christopher J. Kane, MD, FACS; Mark H. Kawachi, MD; Michael Kuettel, MD, MBA, PhD; Richard J. Lee, MD, PhD; Arnold W. Malcolm, MD, FACR; David Miller, MD, MPH; Elizabeth R. Plimack, MD, MS; Julio M. Pow-Sang, MD; Sylvia Richey, MD; Mack Roach, III, MD; Eric Rohren, MD, PhD; Stan Rosenfeld; Eric J. Small, MD; Guru Sonpavde, MD; Sandy Srinivas, MD; Cy Stein, MD, PhD; Seth A. Strope, MD, MPH; Jonathan Tward, MD, PhD; and Patrick Walsh, MD
NCCN Prostate Cancer Panel Members