Download Comparison of Recommendations by Urologists and

ORIGINAL CONTRIBUTION
Comparison of Recommendations
by Urologists and Radiation Oncologists
for Treatment of Clinically Localized
Prostate Cancer
Floyd J. Fowler, Jr, PhD
Mary McNaughton Collins, MD, MPH
Context Multiple treatment options are available for men with prostate cancer, but therapeutic recommendations may differ depending on the type of specialist they consult.
Peter C. Albertsen, MD, MS
Anthony Zietman, MD
Objective To define and contrast the distribution of management recommendations
by urologists and radiation oncologists for a spectrum of men with prostate cancer.
Design, Setting, and Participants Mail survey sent in 1998 to a random sample
of physicians in the United States, who were listed as urologists (response rate 64%,
n=504) and radiation oncologists (response rate 76%, n=559) in the American Medical Association Registry of Physicians and practicing at least 20 hours per week.
Diana B. Elliott, BA
Michael J. Barry, MD
A
BOUT 180 400 MEN WILL BE
diagnosed as having prostate cancer in the United
States this year, most with
clinically localized disease.1 The majority of these men will choose among
3 primary therapies: radical prostatectomy, external beam radiotherapy, or
brachytherapy.
The choice among these therapies is
not easy. Because most prostate cancers are found in men in their 60s and
70s, and because these cancers generally grow slowly, many prostate cancer patients are destined to die of competing medical problems.2 For others,
especially men with poorly differentiated tumors or high prostate-specific
antigen (PSA) levels, these therapies
may not be curative. Moreover, while
cohort studies following surgery and external beam radiotherapy patients for
10 to 15 years have been done,3 patients receiving contemporary brachytherapy have not been followed up that
long.4 Meanwhile, all of these therapies have the potential to create adverse effects or complications.
For editorial comment see p 3258.
Main Outcome Measure Questionnaire addressing beliefs and practices regarding prostate cancer management.
Results Forty-three percent of radiation oncologists vs 16% of urologists would recommend routine prostate-specific antigen testing for men aged 80 years and older.
For men with moderately differentiated, clinically localized cancers, and a more than
10-year life expectancy, 93% of urologists chose radical prostatectomy as the preferred treatment option, while 72% of radiation oncologists believed surgery and external beam radiotherapy were equivalent treatments. For most tumor grades and prostate-specific antigen levels, both specialty groups were significantly more likely to
recommend the treatment in their specialty than the other treatment. Both groups reported giving patients similar estimates of the risks of complications due to surgery
and radiation. Neither group favored watchful waiting in their treatment management except for a subset of men with life expectancies of less than 10 years and cancers with very favorable prognoses (Gleason score of 3 or 4 and prostate-specific antigen level #5 ng/mL).
Conclusions Based on this study, while urologists and radiation oncologists do agree
on a variety of issues regarding detection and treatment of prostate cancer, specialists
overwhelmingly recommend the therapy that they themselves deliver.
www.jama.com
JAMA. 2000;283:3217-3222
The clinical judgment of the physicians who counsel patients can play a
critical role in the treatments chosen.
In a 1988 survey, urologists and radiation oncologists were asked what they
personally would do if they were diag-
nosed as having clinically localized
prostate cancer. In that survey, 79% of
US urologists said they would choose
a radical prostatectomy, while 92% of
radiation oncologists said they would
choose external beam radiotherapy.5
Author Affiliations: Center for Survey Research, University of Massachusetts, Boston (Dr Fowler and Ms
Elliott); Medical Practices Evaluation Center (Drs
McNaughton Collins and Barry) and the Department
of Radiation Oncology (Dr Zietman), Massachusetts
General Hospital, Boston; and the Division of
Urology, University of Connecticut Health Center,
Farmington (Dr Albertsen).
Corresponding Author and Reprints: Michael J. Barry,
MD, Medical Practices Evaluation Center, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA 02114 (e-mail: [email protected]).
©2000 American Medical Association. All rights reserved.
(Reprinted) JAMA, June 28, 2000—Vol 283, No. 24
Downloaded from www.jama.com on November 11, 2007
3217
PROSTATE CANCER TREATMENT BY SPECIALTY
Table 1. Selected Respondent Characteristics
Radiation
Oncologists, %
(n = 559)
Urologists, %
(n = 504)
Age, y
,40
40-49
24
38
11
30
50-59
29
40
P Value
,.001
$60
9
19
Sex
Men
Women
83
17
99
1
Type of medical practice
Solo
Single specialty group
12
70
27
54
18
18
Average clinical time*
94
94
.96
Source of income
Salaried
Mixture
30
12
14
12
,.001
58
74
17
83
21
79
Multispecialty group
Fee-for-service
Working at a hospital with a
residency training program
Yes
No
,.001
,.001
.07
*Indicates the percentage of total professional time spent in clinical practice.
wanted to see whether the different specialties continued to have such polar
views regarding treatment 10 years
later, well into the era of PSA testing.
To these ends, in 1998, we surveyed a
nationwide random sample of practicing US urologists and radiation oncologists.
Figure 1. Recommendation of Routine
Prostate-Specific Antigen (PSA) Testing
for Men by Age
% Recommending Routine PSA Testing
Radiation Oncologists (n = 559)
Urologists (n = 504)
P<.001 P = .92 P<.001
96 98 98 95
90
89 P<.001
100
77
80
60
40
51
P<.001
43
P = .93
24 25
16
20
0
40-49
50-59
60-69
70-74
75-79
>80
Patient Age, y
Radiation oncologists and urologists were asked: “Do
you recommend that primary care physicians include
PSA testing as a part of the routine physical examination for men who are at average risk of prostate cancer, who are [each age group]?”
Obviously, depending on which physicians they consult, patients might well
expect to get different counsel about optimal management.
We were interested in extending our
understanding of the differences between specialties beyond simply their
preferences for treatment. We also
METHODS
A random sample of physicians who
listed their specialty as either urology
or radiation oncology were selected
from the American Medical Association Master List of Physicians. Subsequently, the offices of the sampled physicians were contacted by telephone to
verify the address and specialty, that
they were not in residency training, and
that they were in clinical practice for
at least 20 hours weekly.
Physicians then were sent a pretested questionnaire, a cover letter,
and $10. A reminder postcard was
sent to all sampled individuals;
another survey instrument and cover
letter were sent to nonrespondents
after about 3 weeks. Finally, for
those physicians who had not
responded to the questionnaire,
3218 JAMA, June 28, 2000—Vol 283, No. 24 (Reprinted)
follow-up telephone calls were made
to the physicians’ offices to encourage response and to identify subjects
who needed another questionnaire.
The survey instrument for urologists contained questions about the diagnosis and treatment of benign prostatic hyperplasia and prostatitis, as well
as prostate cancer. The instrument for
radiation oncologists focused almost exclusively on prostate cancer. Whenever it made sense, comparable questions were asked of both specialties.
RESULTS
Questionnaires were returned by 76%
of eligible radiation oncologists
(n = 559) and 64% of eligible urologists (n=504). TABLE 1 compares the
characteristics of the respondents in the
2 specialties. Responding urologists
were older, more often male, more
likely to be in solo practice, and less
likely to be salaried. When respondents and nonrespondents were compared, using data from the file from
which the sample was drawn, no significant differences were noted in terms
of age or region of the country. Urologists who graduated from medical
school less than 20 years previously
were more likely to respond than earlier graduates. Physicians in multispecialty groups were also more likely to
respond than physicians in solo practice in both specialties.
FIGURE 1 compares both groups of
specialists’ answers to questions about
their recommendations for routine PSA
testing. For men up through age 70
years, members of the 2 specialties made
similar recommendations. Urologists
are slightly more aggressive about
screening than radiation oncologists but
significantly more aggressive when patients are men in their 50s. The clearer
trend, however, is the much more aggressive stance of radiation oncologists regarding PSA testing for men 70
years and older, and particularly for
men older than 74 years. For example, while only 16% of urologists recommend routine PSA testing for men
older than 80 years, 43% of the radiation oncologists do so.
©2000 American Medical Association. All rights reserved.
Downloaded from www.jama.com on November 11, 2007
PROSTATE CANCER TREATMENT BY SPECIALTY
FIGURE 2 presents these specialists’ beliefs about when aggressive treatments
actually have a survival benefit. This figure presents the percentage of respondents saying that there is “definitely” or
“probably” a survival benefit for each of
the 3 main therapies for men with clinically localized, moderately differentiated prostate cancer and less or more
than a 10-year life expectancy, respectively. Although there are numerous statistically significant differences between the 2 groups given the large
sample sizes, there is also considerable
consistency in their answers. The majority of both groups of specialists think
that all 3 therapies have survival benefit
for men with a 10-year or longer life expectancy; only a minority think there is
benefit from any of the treatments for
men with less than a 10-year life expectancy. More of both types of specialists,
though, believe that radiation, either by
external beam or brachytherapy, is more
likely to offer a survival benefit for men
with less than a 10-year life expectancy
than a radical prostatectomy. Indeed, that
perception is slightly but significantly
more common among urologists than
among radiation oncologists. Figure 2
also demonstrates that members of each
specialty are generally somewhat more
likely than those in the other specialty
to believe in the efficacy of the treatments that they perform, and are also a
little less positive about the survival benefits of the treatment offered by the other
specialty group.
T ABLE 2 presents physicians’ responses to questions about head-tohead comparisons of the effectiveness
of the 3 major therapies. When comparing radical prostatectomy and external beam radiotherapy for patients
with life expectancies of 10 years or
longer, urologists are almost all convinced (93%) that radical prostatectomy is better. On the other hand, radiation oncologists’ perceptions (72%)
are that surgery and radiotherapy are
equivalent. Almost a third of urologists think neither treatment has survival value for men with less than a 10year life expectancy, while only 19% of
radiation oncologists agree.
When deciding among treatment options, prostate cancer patients need to
consider not only the effectiveness of
the options at extending life, but also
their adverse effects. Sexual dysfunction and incontinence are 2 potential
adverse effects of aggressive therapy for
prostate cancer. How are the likelihoods of these adverse effects presented to patients by urologists and radiation oncologists? TABLE 3 presents
the risks of these complications that the
respondents said they quote to their patients. Table 3 is most striking in how
similarly the 2 groups estimate the
probability of complications associated with surgery and radiation.
Respondents were also asked to
choose their preferred treatment for patients with tumors of varying Gleason
scores and PSA levels. In FIGURE 3 and
FIGURE 4, the patient profiles are ordered based on the decreasing likelihood that such a cancer would be organconfined at surgical staging.6 Subjects
were given the options of expectant management (watchful waiting) and androgen deprivation (as primary therapy) in
addition to the potentially curative therapies. For this analysis, both forms of radiotherapy were considered together.
Both groups of specialists have some
members (10%-20%) who are willing
to consider watchful waiting for patients with cancers with Gleason scores
Figure 2. Treatment Expectations for
Clinically Organ-Confined, Moderate-Grade
Prostate Cancers and Less or More Than
10-Year Life Expectancies
Urologists (n = 504)
Radiation Oncologists (n = 559)
Patients With Life
Expectancy <10 y
38
35
Patients With Life
Expectancy ≥10 y
Brachytherapy
External
Beam
Radiation
46
39
14
22
66
82
67
86
98
Radical
Prostatectomy
100 80 60 40 20 0
79
0 20 40 60 80 100
% Who Say Treatments Have a Survival Benefit
The left side of the figure shows the responses when
asked: “For a patient with clinically localized cancer
(stage A or B, moderate grade), who has a life expectancy of less than 10 years, do you think that [name
of treatment] as the primary therapy offers a survival
benefit?” The right side of the figure shows the responses when asked: “For a patient with clinically localized cancer (stage A or B, moderate grade), whose
life expectancy is clearly greater than 10 years, do you
think [name of treatment] as the primary therapy offers a survival benefit?”
Table 2. Comparison of Treatments for Organ-Confined, Moderate-Grade Prostate Cancer*
Comparison of Treatments
(Patient Life Expectancy)†
Radical prostatectomy vs external beam radiation (,10 y)
Radiation better
Both the same
Prostatectomy better
Neither offers survival benefit
Do not know
Radical prostatectomy vs external beam radiation ($10 y)
Radiation better
Both the same
Prostatectomy better
Neither offers survival benefit
Radiation
Oncologists, %
Urologists, %
(n = 549)
10
68
(n = 501)
9
40
2
17
19
32
1
(n = 549)
3
72
2
(n = 501)
0
6
20
93
3
0
2
(n = 548)
21
53
1
(n = 494)
30
33
External beam radiation better
11
13
Neither offers survival benefit
2
4
13
20
Do not know
Brachytherapy vs external beam radiation ($10 y)
Brachytherapy better
Both the same
Do not know
*P,.001 for all comparisons.
†Exact question wording: “For a patient with clinically localized cancer (stage A or B, moderate grade), who has a life
expectancy clearly [less or greater] than 10 years, how do you think [treatment 1 and treatment 2] compare in terms
of the survival benefit they offer?”
©2000 American Medical Association. All rights reserved.
(Reprinted) JAMA, June 28, 2000—Vol 283, No. 24
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3219
PROSTATE CANCER TREATMENT BY SPECIALTY
Table 3. Average Percentage Estimates of Chance for Loss of Sexual Function
and Some Permanent Wetness for Various Prostate Cancer Treatment Options*
Permanent Loss
of Sexual Function, %
Treatment†
Radiation
Oncologists
(n = 547)
Urologists
(n = 489)
External beam radiation
36.8
Brachytherapy
23.4
Non–nerve-sparing
prostatectomy
Some Permanent
Wetness, %
39.2
Radiation
Oncologists
(n = 540)
3.2
Urologists
(n = 488)
5.7
30.7
3.7
4.9
93.3
87.2
25.2
13.3
Unilateral nerve-sparing
prostatectomy
59.3
60.4
20.8
12.2
Bilateral nerve-sparing
prostatectomy
45.7
Figure 3. Recommendations of Androgen
Deprivation and Watchful Waiting for Men
With Clinically Localized Prostate Cancers
Urologists (n = 504)
Radiation Oncologists (n = 559)
Gleason
PSA Level,
&
Score
ng/mL
36
38
8
>20
1
1
7
>20
1
8
10-20
2
4
7
10-20
5
3
8
5
7
5
5-6
10-20
5-6
5
4
5
3
5
17
24
51.4
19.7
12.0
15
11
*All differences between specialties were significant (P,.01) with the exception of estimates for the permanent loss of
sexual fuctioning for unilateral nerve-sparing prostatectomy (P = .99). The number of respondents differed slightly
from question to question due to nonresponse. The numbers reflected are the maximum number of respondents to
questions in this series.
†Exact question wording: “A patient of yours with prostate cancer is 65 and has full sexual function and no sign of
incontinence. What would you tell him his chances are of having loss of sexual functioning (permanent loss of the
ability to have intercourse) and some incontinence (indefinitely experiencing leaking or wetness, enough to regularly
wear a pad) for the following treatment options?”
1
of 3 or 4 and PSA levels no higher than
5 ng/mL. Beyond that low-risk subset,
essentially no one in either group is willing to recommend watchful waiting
(Figure 3).
As one would expect from the preceding data, the majority of both groups
of specialists would recommend for
most patients the therapy that they
themselves deliver. However, there is
a subset of radiation oncologists who
indicated a preference for surgery for
low-grade, low-PSA tumors. There are
very few urologists who prefer radiation for such tumors (Figure 4).
As Gleason scores reach 7 or 8, both
groups start to consider androgen deprivation as a primary therapy (Figure
3). Urologists also begin to recommend radiation more often in relationship to surgery as Gleason scores and
PSA levels increase (Figure 4).
As the probability of organ-confined
disease decreases, urologists become divided about the value of surgery. For
tumors with Gleason scores of 8 or
higher, or a Gleason score of 7 with a
high PSA level, they become as likely
to recommend androgen deprivation or
radiation as they do surgery. However, there is a substantial minority who
continue to recommend surgery even
when tumors are likely to be extracapsular. Radiation oncologists, on the
other hand, continue to recommend radiation for higher-risk tumors.
Finally, physicians were asked
whether they believed that the 3 main
potentially curative prostate cancer
therapies are overused or underused in
the United States (TABLE 4). A majority of radiation oncologists believe that
radical prostatectomy is overused
(82%), and about half think that radiation and brachytherapy are underused. In contrast, 51% of urologists
think that radical prostatectomy is used
at about the right rate and 37% think
that external beam radiation is overused. Substantial percentages of both
radiation oncologists and urologists believe that brachytherapy is both overused and underused, and a higher proportion express no opinion than for the
other 2 primary therapies.
COMMENT
Although urologists and radiation oncologists differed in many of their beliefs
regarding prostate cancer treatment,
they also demonstrated agreement on
a variety of issues. First, despite controversy over the value of PSA screening,7,8 responding physicians in both
these specialties are virtually unanimous in their recommendation that PSA
testing be done routinely at least until
around age 75 years. For men older
3220 JAMA, June 28, 2000—Vol 283, No. 24 (Reprinted)
1
2
40
30
20
10
0
% Who Would
Recommend
Androgen Deprivation
1
1
1
1
11
13
18
22
0
10
20
30
% Who Would
Recommend
Watchful Waiting
The left side of the figure shows the responses recommending androgen deprivation treatment when
asked: “A prostate cancer patient of yours is 65, in
good health, and has a negative digital rectal examination result and no evidence of extraprostatic spread.
Which primary treatment would you be most likely
to recommend for localized prostate cancer if this patient has the following biopsy results [list of Gleason/
PSA profiles]?” The right side of the figure shows the
responses recommending watchful waiting.
than 75 years, the 2 specialties differ,
with radiation oncologists being considerably more positive about testing
older men. This position is consistent
with radiation oncologists’ perceptions that they have a therapy to offer
that (according to nearly a majority) is
beneficial to men even with less than a
10-year life expectancy.
Second, despite the lack of published supporting evidence from randomized clinical trials, the vast majority of physicians in both specialties
believe that all 3 therapies offer a sur-
©2000 American Medical Association. All rights reserved.
Downloaded from www.jama.com on November 11, 2007
PROSTATE CANCER TREATMENT BY SPECIALTY
Figure 4. Recommendations of Radical
Prostatectomy and Radiation Therapy for
Men With Clinically Localized Prostate
Cancer
Table 4. Perceived Rates of Use
of Treatments for Prostate Cancer*
Treatment†
Radical prostatectomy
Overused
Underused
Urologists (n = 504)
Radiation Oncologists (n = 559)
1
40
1
48
1
71
1
72
3
91
8
85
4
93
20
79
26
73
25
8
7
8
7
8
7
5-6
>20
75
37
10-20
87
27
10-20
95
23
94
8
91
5
4
5
5
(n = 499)
34
11
16
51
2
4
(n = 552)
(n = 499)
13
37
Underused
50
5
Used at about
the right rate
No opinion
35
51
Brachytherapy
Overused
Underused
2
7
(n = 547)
26
44
(n = 496)
30
27
20
21
10
22
Used at about the
right rate
No opinion
*P,.001 for all comparisons.
14
10-20
5-6
3
60
42
>20
5
External beam
radiation
Overused
35
5
(n = 552)
82
0
Used at about the
right rate
No opinion
Gleason
PSA Level,
&
Score
ng/mL
28
Radiation
Oncologists Urologists
94
6
79
10
61
9
53
100 80 60 40 20 0
0 20 40 60 80 100
% Who Would
Recommend
Radical
Prostatectomy
% Who Would
Recommend
External Beam
Radiation
The left side of the figure shows the responses recommending radical prostatectomy when asked: “A
prostate cancer patient of yours is 65, in good health,
and has a negative digital rectal examination result and
no evidence of extraprostatic spread. Which primary
treatment would you be most likely to recommend for
localized prostate cancer if this patient has the following biopsy results [list of Gleason/PSA profiles]?”
The right side of the figure shows the responses recommending external beam radiation.
vival advantage for men with a 10year or more life expectancy.
Third, with respect to patients with
less than a 10-year life expectancy, only
a minority of members of either specialty thinks that any therapy offers a
survival advantage. Within both groups,
however, there are more physicians who
think that radiation therapy offers a survival advantage than think that surgery does.
Fourth, specialists generally agree on
the probabilities of complications of all
3 treatments. Both groups perceive surgery as being more likely to produce incontinence and sexual dysfunction than
radiotherapy. Both urologists and radiation oncologists are generally convinced that nerve-sparing surgery substantially reduces the rate at which
patients experience sexual dysfunction. Disagreements about probabilities of adverse effects, then, do not account for the differences in treatment
recommendations noted between the
specialties. Some recent studies actually suggest, however, that these estimated risks of complications for all 3
treatments may be low, and particularly low for nerve-sparing radical prostatectomy.9-13
Fifth, physicians from the 2 specialties are remarkably similar in the extent to which they would recommend
either watchful waiting or androgen
deprivation as primary therapies for particular subsets of men based on Gleason scores and PSA levels. Less than
25% of members of either specialty
would recommend watchful waiting to
men with a tumor with a Gleason score
of 3, despite the fact that these patients appear to have an essentially normal life expectancy without aggressive treatment. 14 Members of both
©2000 American Medical Association. All rights reserved.
specialties feel much more comfortable if patients with any degree of prostate cancer receive one of the major primary therapies. When the Gleason
scores (7-8) and PSA levels ($10 ng/
mL) are higher, increasing numbers in
both specialties, eventually nearing half,
would recommend androgen deprivation as the primary therapy. Radiation
oncologists continue to recommend radiation for tumors with a higher likelihood of capsular penetration, while
urologists appear more dubious about
the value of surgery. This finding may
reflect a difference in perspectives about
when the 2 local therapies are likely to
be still curative; that is, radiation oncologists may believe tumors with some
degree of capsular penetration may still
be effectively treated with radiation,
while urologists may doubt that surgery will cure such tumors.
Sixth, despite a relative shortage of
long-term follow-up data, members of
both specialties generally seem to accept brachytherapy as being at least as
effective as external beam radiotherapy. Urologists seem to be slightly
more positive about brachytherapy than
about external beam radiation therapy.
Of course, the most dramatic difference between these 2 groups of specialists is that members of each specialty tend to believe in the therapy that
they themselves deliver. Radiation oncologists (72%) tend to believe that their
therapy is just as good as radical prostatectomy for men with moderately differentiated, clinically localized cancer
while urologists (93%) are overwhelmingly convinced that radical prostatectomy is better. This difference is critical in understanding what treatment
recommendations patients are likely to
hear. Presumably, the radiation therapists can justify their preference for recommending external beam radiotherapy on the basis that they believe
it works just as well as surgery. In contrast, urologists believe that while men
who have surgery do indeed have
higher risks of sexual dysfunction and
incontinence, cancer control is better
with surgery, and thus radical prostatectomy is preferred.
(Reprinted) JAMA, June 28, 2000—Vol 283, No. 24
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3221
PROSTATE CANCER TREATMENT BY SPECIALTY
While clinical trials have not proven
that patient outcomes are improved by
aggressive treatment with surgery or radiation, neither have they proven these
treatments ineffective. Given our findings, it is also important to point out
that the descriptions of the effectiveness of surgery and radiation therapy
that patients receive from urologists and
radiation oncologists would be expected to be quite different. Although
some patients might find it confusing
to hear quite different treatment recommendations from experienced physicians with access to the same medical literature, scheduling consultations
ing diagnosed as having prostate cancer than will ever die of it, expectant
management would appear to be appropriate for some men. More research is needed to define those subgroups of men for whom an expectant
approach is a reasonable, or even optimal, management strategy. An added
challenge will be to ensure any such insights are effectively communicated to
patients facing a treatment decision for
prostate cancer.
with a member of each specialty may
be the best approach to ensure that patients get a balanced picture regarding
aggressive treatment options before
making a decision.
Neither group of specialists studied
was supportive of expectant management for any but a limited subset of
men; primary care physicians appear no
more enthusiastic.15 Interestingly, however, when patients hear comprehensive presentations regarding the risks
and benefits of all potential treatments, a substantial minority appears
to choose expectant management.16,17
Given that many more men are now be-
Funding/Support: This study was funded by grant HS
08397 from the Agency for Healthcare Research and
Quality (formerly the Agency for Health Care Policy
and Research) to the Patient Outcomes Research Team.
7. US Preventive Services Task Force. Screening for
prostate cancer: commentary on the recommendations of the Canadian Task Force on the periodic
health examination. Am J Prev Med. 1994;10:187193.
8. American College of Physicians. Screening for prostate cancer: Clinical Guideline, Part III. Ann Intern Med.
1997;126:480-484.
9. Fowler FJ, Barry MJ, Lu-Yao G, et al. Outcomes of
external-beam radiation therapy for prostate cancer:
a study of Medicare beneficiaries in three Surveillance, Epidemiology, and End Results areas. J Clin Oncol. 1996;14:2258-2265.
10. Jonler M, Messing EM, Rhodes RP, et al. Sequelae of radical prostatectomy. Br J Urol. 1994;74:
352-358.
11. Jonler M, Ritter MA, Brinkman R, et al. Sequelae
of definitive radiation therapy for prostate cancer localized to the pelvis. Urology. 1994;44:876-882.
12. Talcott JA, Rieker P, Propert KJ, et al. Patientreported impotence and incontinence after nerve-
sparing radical prostatectomy. J Natl Cancer Inst. 1997;
89:1117-1123.
13. Stanford J, Feng Z, Hamilton A, et al. Urinary and
sexual function after radical prostatectomy for
clinically localized prostate cancer: The Prostate
Cancer Outcomes Study. JAMA. 2000;283:354360.
14. Albertsen PC, Fryback DG, Storer BE, et al. Longterm survival among men with conservatively treated
localized prostate cancer. JAMA. 1995;274:626631.
15. Fowler FJ, Bin L, McNaughton Collins M, et al. Prostate cancer screening and beliefs about treatment efficacy: a national survey of primary care physicians and
urologists. Am J Med. 1998;104:526-532.
16. Wilt TJ, Brawer MK. The Prostate cancer Intervention Versus Observation Trial (PIVOT). Oncology. 1997;11:1133-1139.
17. Ontel E, Hamond C, Wasson JH, et al. Assessment of the feasibility and impact of shared decision
making in prostate cancer. Urology. 1998;51:63-66.
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