PRACTICE PATTERNS OF CANADIAN UROLOGISTS IN BENIGN PROSTATIC HYPERPLASIA AND PROSTATE CANCER

0022-5347/00/1632-0499/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 163, 499 –502, February 2000 Printed in U.S.A.

PRACTICE PATTERNS OF CANADIAN UROLOGISTS IN BENIGN PROSTATIC HYPERPLASIA AND PROSTATE CANCER ERNEST W. RAMSEY, MOSTAFA ELHILALI, S. LARRY GOLDENBERG, CURTIS J. NICKEL, RICHARD NORMAN, JEAN PAUL PERREAULT, BRUCE PIERCY AND JOHN TRACHTENBERG FOR THE CANADIAN PROSTATE HEALTH COUNCIL From the Departments of Urology, University of Manitoba, Health Sciences Centre, Winnipeg, Manitoba, McGill University, Royal Victoria Hospital and Universite de Montreal, St. Luc’s Hospital, Montreal, Quebec, University of British Columbia, Vancouver Hospital, Vancouver and British Columbia Greater Hospital Society, Victoria, British Columbia, Queen’s University, Kingston General Hospital, Kingston and University of Toronto, Toronto Hospital, Toronto, Ontario, and Dalhousie University, Nova Scotia Prostate Centre, Halifax, Nova Scotia, Canada

ABSTRACT

Purpose: We reviewed the practice patterns of Canadian urologists in benign prostatic hyperplasia (BPH) and prostate cancer, and assessed the changes that occurred between 1995 and 1998. Materials and Methods: In 1995 and 1998 questionnaires were mailed to all active members of the Canadian Urological Association who practiced adult urology in Canada. Many questions were similar, allowing for the assessment of changes in practice patterns. Results: A number of changes were observed between 1995 and 1998. Cystoscopy and imaging of the upper urinary tract were used less often to evaluate uncomplicated cases of BPH. However, 39% of respondents continued to perform cystoscopy routinely. Finasteride was no longer administered in men with a smaller prostate. In 1998 before radical prostatectomy 28% of respondents routinely performed a bone scan, 29% cystoscopy and 57% chest x-ray. The number believing that maximal androgen blockade is the most effective hormonal therapy decreased from 90% to 62%, while 24% reported in the 1998 survey that they frequently administered intermittent hormonal therapy. Comparison with an American study from 1995 indicated that American urologists used the American Urological Association symptom score and performed a prostate specific antigen test more frequently than Canadian urologists. However, Canadian urologists performed cystoscopy more frequently. Conclusions: These surveys provide a useful insight into the variations in clinical practice of Canadian urologists and help to determine whether changes are occurring in regard to the development of practice guidelines. They also indicate the need to develop further guidelines, and ensure that these guidelines are widely promoted and accepted by the urological community. KEY WORDS: prostate; practice patterns, clinical; prostatic hyperplasia; prostatic neoplasms

The evaluation and management of benign prostatic hyperplasia (BPH) and prostate cancer have changed markedly during the last 10 years. For BPH these changes have included the development of guidelines for investigation, use of standard symptom scores and quality of life assessment, introduction of medical therapy and new technologies, and appreciation of the importance of patient preferences in treatment decisions. Treatment options at all stages of prostate cancer remain controversial and present difficult decisions for patients and physicians. Despite a large volume of information it remains difficult to produce definitive guidelines for managing many clinical situations related to these diseases and, as a result, there remain wide variations in patterns of practice. To determine current practice patterns and changes in such patterns of Canadian urologists we performed a survey of Canadian urologists in 1995 and again in 1998.

in Canada. Questions involved the diagnosis and treatment, and standard clinical scenarios with a choice of management options. The 1998 questionnaire contained a number of questions identical to those in 1995 as well as questions on the investigation of BPH that were identical to those in the 1995 survey of a random sample of urologists in the United States.1 RESULTS

Responses were obtained from 206 urologists (54.5%) to the 1998 survey, similar to that of the 1995 survey. In 1998, 59% of respondents were community based versus 66% in 1995. Table 1 shows respondent distribution by age and years in

TABLE 1. Demographics of respondents % Respondents Age

MATERIALS AND METHODS

Questionnaires were mailed to all active members of the Canadian Urological Association who practiced adult urology Accepted for publication September 3, 1999. Supported by the Canadian Urological Association.

Younger than 40 40–49 50–59 Older than 60

499

% Respondents Practice Yrs.

1998

1995

25 36 24 15

23 30 32 15

Less than 10 10–19 20–29 Greater than 30

1998

1995

35 30 28 7

27 33 30 10

500

PRACTICE PATTERNS OF CANADIAN UROLOGISTS

practice. Appendix 1 shows responses to a common clinical presentation of BPH. Although 61% to 70% of respondents used the American Urological Association (AUA) symptom score, 56% believed that improvements were needed. The number of respondents performing cystoscopy in such patients decreased from 1995 to 1998 but in 1998 more than a third routinely performed cystoscopy in symptomatic BPH cases. While only 6% of urologists still used excretory urography (IVP) to evaluate such patients, 23% evaluated the upper tract with renal ultrasonography. The main difference between 1995 and 1998 was that 27% of respondents recommended finasteride as treatment in 1995 but none recommended it in 1998 (Appendix 2). The 51% of respondents who administered an a-blocker increased to 91%. Presumably this finding partially reflects data on the lack of efficacy of finasteride in men with a smaller prostate.2 In another case scenario with a prostate volume of 80 cc 41% chose an a-blocker, 32% finasteride, 13% either and 14% both medications. The question of prostate size was also addressed in regard to type of surgery for patients in persistent urinary retention. For a 64-year-old man with a prostate volume of 105 cc 46% of respondents elected transurethral prostatic resection, 44% retropubic prostatectomy and 6% suprapubic transvesical prostatectomy. Table 2 lists the frequency of use of various studies for the initial evaluation of a man with suspected BPH, and compares the frequency of use by Canadian urologists in 1998 to that by American urologists in a survey done in 1995. The American study was based on a survey of 586 urologists, of whom 394 (67%) responded. American urologists appeared to use the AUA symptom score and perform a prostate specific antigen (PSA) test more frequently than Canadian urologists. However, Canadian urologists performed cystoscopy and measured serum creatinine more frequently. In regard to other investigations there appeared to be minimal differences. Appendix 3 shows the choice of treatment in the 1998 survey for men in whom medical therapy failed. Standard transurethral prostatic resection remained the most common choice (69% of respondents), while 67% indicated that they used transurethral prostatic incision for prostates less than 30 cc. Replacing the term prostatism with lower urinary tract symptoms, and irritative and obstructive symptoms with storage and voiding symptoms was favored by only 49% and 26% of respondents, respectively. Appendix 4 shows responses to a series of questions on prostate cancer from the 1998 survey. Respondents were also asked whether they performed radical prostatectomy and, if so, how many they performed yearly (table 3). Of the respondents 6% performed less than 5 radical prostatectomies yearly, 21% 5 to 10, 42% 11 to 20 and 30% more than 20. Appendix 5 lists responses on hormonal therapy for prostate cancer and compares 1998 to 1995 as available. The proportion of respondents who believed that maximal androgen blockade was the most effective hormonal therapy for ad-

TABLE 3. Number of radical prostatectomies performed each year No. Prostatectomies/Yr.

No. Respondents (%)

Less than 5 5–10 11–20 Greater than 20

10 (6) 33 (21) 64 (42) 46 (30)

vanced disease decreased from 90% in 1995 to 62% in 1998. There has been considerable interest in intermittent hormonal therapy and, although it is generally considered to be investigational, almost a quarter of respondents administered it frequently. DISCUSSION

Despite the voluminous literature on BPH and prostate cancer many uncertainties exist regarding the appropriate evaluation and treatment of individuals. Guidelines have been developed in a number of areas but wide variation exists among urologists in the approach to many of these problems. Comparison between 1998 and 1995 reveals some changes in practice of Canadian urologists. For example, there has been a decrease in cystoscopy for the routine evaluation of patients with suspected BPH. However, 39% of respondents still routinely performed cystoscopy to evaluate BPH in 1998 despite the guidelines reported by McConnell et al, who stated that “Urethrocystoscopy is not recommended to determine the need for treatment. This test is recommended for men with prostatism who have a history of microscopic or gross hematuria, urethral stricture disease (or risk factors, such as history of urethritis or urethral injury), bladder cancer or prior lower urinary tract surgery (especially prior transurethral prostatic resection). To help the surgeon determine the most appropriate technical approach, urethroscopy is an optional test in men with moderate-to-severe symptoms who have chosen (or require) surgical or invasive therapy.”3 Koyanagi et al also placed endoscopic evaluation of the lower urinary tract in the optional category, indicating that it was not recommended for an otherwise healthy patient in whom initial evaluation was consistent with benign prostatic obstruction.4 McConnell3 and Koyanagi4 et al also recommended that imaging of the upper urinary tract by ultrasonography or IVP should not be done in an otherwise healthy patient in whom the initial evaluation is consistent with uncomplicated benign obstruction. Exceptions include those with a history of or current upper urinary tract infection, microscopic or gross hematuria, history of urolithiasis or renal insufficiency (when ultrasonography is the preferred imaging study). Although there was a decrease in upper tract imaging between 1995 and 1998 with IVP and renal ultrasound decreasing from 9% to 6% and 37% to 23%, respectively, renal ultrasonography was still performed by 23% of respondents to

TABLE 2. Respondents who reported performing certain studies for the initial evaluation of a man with symptoms suggesting BPH % Canadian (American) Respondents

AUA symptom score Serum creatinine Serum PSA Post-void residual urine measurement: Catheterization Ultrasound (bladder scan) IVP Renal ultrasound Transrectal ultrasound Cystoscopy Uroflowmetry Pressure flow study

Almost Always

More Than Half of Time

About Half of Time

Less Than Half of Time

Rarely

Never

30 (45) 35 (13) 56 (87)

14 (18) 11 (13) 26 (8)

11 (9) 9 (11) 8 (2)

17 (9) 15 (23) 6 (2)

21 (12) 25 (37) 2 (1)

7 (6) 4 (2) 0.5 (0)

5 (4) 17 (19) 3 (2) 10 (1) 2 (2) 19 (8) 24 (21) 2 (1)

1 (10) 14 (20) 2 (7) 6 (7) 1 (3) 20 (15) 22 (19) 3 (1)

7 (11) 9 (13) 3 (8) 9 (10) 8 (6) 18 (19) 8 (13) 1 (2)

16 (22) 22 (18) 11 (18) 25 (28) 19 (24) 24 (29) 18 (15) 19 (9)

47 (43) 27 (18) 48 (57) 39 (42) 40 (44) 18 (27) 21 (21) 40 (46)

24 (11) 11 (12) 34 (8) 9 (12) 32 (20) 1 (2) 7 (11) 35 (39)

501

PRACTICE PATTERNS OF CANADIAN UROLOGISTS

evaluate uncomplicated cases of symptomatic BPH. In 1998 only a third of Canadian urologists acted as the surgeon who performed transrectal ultrasound guided prostate biopsy. Despite the time difference between the 1998 Canadian and 1995 American surveys comparison is reasonable. AUA symptom score use and PSA determination were more commonly done by American urologists, while serum creatinine determination was more commonly done by Canadian urologists. In each country AUA symptom score does not appear to have achieved the general acceptance and use that may have been expected. Of Canadian respondents 56% indicated that it must be improved. Cystoscopy appears to be more commonly done in Canada for the initial evaluation of suspected BPH. Medical therapy is the most common recommendation for men with uncomplicated BPH and moderate symptoms. In 1995 finasteride was the choice of 27% of urologists for patients with a small prostate, while in 1998 finasteride was not chosen by any, indicating that urologists were aware that finasteride is mainly efficacious in patients with a prostate of greater than 40 cc.2 For a patient with a larger prostate, for example 80 cc, 41% of respondents chose an a-blocker and 32% finasteride in 1998, while 14% administered combined a-blocker and finasteride. It appears that in 1998 newer technologies for treating BPH had only a limited role. For patients in whom medical therapy failed 69% of urologists preferred standard transurethral prostatic resection and another 17% performed variations of transurethral prostatic resection, that is use of a thick and/or wedge loop or vaporization. Respondents appeared to be evenly divided on whether the term prostatism should be replaced by lower urinary tract symptoms, while only 26% favored changing irritative and obstructive symptoms to storage and voiding symptoms. There was no unanimous agreement among Canadian urologists that asymptomatic men 50 to 70 years old should undergo a yearly digital rectal examination and PSA test, although 87% supported this combination. It is also noteworthy that 30% of urologists older than 50 years had not undergone digital rectal examination and PSA testing. Considerable evidence indicates that bone scans are probably unnecessary as a staging procedure in men with localized prostate cancer and a PSA of less than 10 ng./ml. unless they have bone pain or high grade cancer with a Gleason score of 8 or greater.5, 6 Despite this evidence 28% of respondents performed bone scans before radical prostatectomy in men with a PSA of less than 10 ng./ml. and no skeletal symptoms. It is also of interest that 29% of respondents generally performed cystoscopy before radical prostatectomy. Since lung metastasis is rare in localized prostate cancer, chest x-ray before radical prostatectomy is presumably done as part of the general preoperative evaluation. A large amount of evidence indicates that routine preoperative chest x-ray is unwarranted and should only be done in patients with evidence of pulmonary or cardiac problems.7 Despite this finding chest x-ray was performed before radical prostatectomy by 57% of respondents. The number of respondents who believed that maximal androgen blockade is the most effective hormonal therapy decreased from 90% to 62% between 1995 and 1998, presumably in response to the 1995 meta-analysis that revealed no significant benefit of maximal androgen blockade and another study that confirmed no benefit of adding flutamide to surgical castration.8, 9 However, the lack of consen-

sus on this topic is reflected by the fact that approximately 60% of Canadian urologists still administer combination therapy, more with luteinizing hormone-releasing hormone agonists than with surgical castration. While intermittent hormonal therapy is still considered investigational as its benefit or harm compared to that of standard treatment remains to be shown, it was obviously given frequently, since 74% and 24% of respondents administered it occasionally and frequently, respectively.10 CONCLUSIONS

The results of our current survey provide useful insight into variations in the clinical practice of Canadian and American urologists. They also indicate the need to develop further guidelines based on solid clinical data, and ensure that these guidelines are widely promoted and accepted by the urological community.

APPENDIX 1: A 55-YEAR-OLD MAN IN GOOD HEALTH IS REFERRED WITH MODERATELY SEVERE VOIDING SYMPTOMS. HE IS BOTHERED BY HIS SYMPTOMS AND WISHES TREATMENT. ON RECTAL EXAMINATION HE HAS A 25 CC BENIGN FEELING PROSTATE. URINALYSIS AND CREATININE ARE NORMAL.

Questions Would you use the AUA symptom score for this patient? Do you think the AUA symptom score is of value? Do you think the AUA symptom score needs to be improved? Would you do uroflowmetry? Do you routinely do uroflowmetry in symptomatic BPH patients? Would you do cystoscopy? Do you routinely do cystoscopy in symptomatic BPH patients? Would you do transrectal ultrasound? Do you routinely do transrectal ultrasound in symptomatic BPH patients? Do you have transrectal ultrasound in your private office or clinic? Do you do your own transrectal ultrasound and biopsies? Would you do IVP? Would you do a renal ultrasound? Would you do a post-void residual urine: By catheterization? By ultrasound (bladder scan)?

% Yes 1998

1995

61

70

76

Not applicable

56

Not applicable

58 42

60 37

51 39

73 53

5

6

1

2

27

25

34

31

6 23

9 37

11 56

20 58

502

PRACTICE PATTERNS OF CANADIAN UROLOGISTS

APPENDIX 2: THIS SAME 55-YEAR-OLD MAN ASKS FOR YOUR RECOMMENDATION. IRRITATIVE (STORAGE) SYMPTOM SCORE IS 6/15 AND OBSTRUCTIVE (VOIDING) SYMPTOM SCORE IS 12/20. PEAK URINE FLOW RATE IS 9 ML. PER SECOND. WHAT WOULD YOU RECOMMEND?

% Respondents Watchful waiting Finasteride a-Blocker Transurethral resection/vaporization Transurethral incision of prostate Transurethral needle ablation Transurethral microwave thermotherapy Laser prostatectomy

1998

1995

6 0 91 2 0.5 0 0

10 27 51 7 2 0 0

0

1

APPENDIX 3: A HEALTHY PATIENT WITH MODERATELY SEVERE SYMPTOMS (AUA SCORE 17), PEAK FLOW RATE 9.8 ML. PER SECOND AND A BENIGN PROSTATE OF ABOUT 50 CC IN VOLUME FAILS MEDICAL THERAPY AND WISHES TREATMENT. WHAT IS YOUR PREFERENCE?

Standard transurethral prostatic resection Transurethral prostatic resection using wedge loop Transurethral vaporization Transurethral needle ablation Transurethral microwave thermotherapy Holmium laser resection Visual laser assisted prostatectomy Open enucleation Other

% Respondents 69 8 9 2 1 5 3 0 3

APPENDIX 4: RESPONSES TO QUESTIONS ON PROSTATE CANCER IN 1998 SURVEY

Do you use free/total PSA estimations? Do you routinely use age specific PSA ranges? Do you believe that asymptomatic men aged 50 to 70 years should have an annual DRE and PSA? Have you had a DRE and PSA? (Answer only if you are age 50 years or older) Do you routinely use the TNM system for staging of prostate cancer? Do you do bone scans in men prior to radical prostatectomy if the PSA is less than 10 ng./ml. and no skeletal symptoms? Do you generally perform cystoscopy prior to radical prostatectomy? Do you generally request an x-ray chest prior to radical prostatectomy? If you perform radical prostatectomy, do you ever use the perineal approach?

% Yes 14 80 87 70 68 28 29 57 7

APPENDIX 5: HORMONAL THERAPY FOR PROSTATE CANCER

% Yes Do you believe that maximal androgen blockade is the most effective hormonal therapy for advanced disease? Do you usually add an antiandrogen to: Surgical castration? Medical castration (excluding flare prevention)? Does the cost of these therapies influence your choice? Do you use intermittent hormonal therapy? If yes: Occasionally? Frequently?

1998

1995

62

90

47 60

Not applicable Not applicable

69

80

60

Not applicable

74 24

Not applicable Not applicable

REFERENCES

1. Barry, M. J., Fowler, F. J., Jr., Bin, L. et al: A nationwide survey of practicing urologists: Current management of benign prostatic hyperplasia and clinically localized prostate cancer. J Urol, 158: 488, 1997 2. Boyle, P., Gould, A. L. and Roehrborn, C. G.: Prostate volume predicts outcome of treatment of benign prostatic hyperplasia with finasteride: meta-analysis of randomized clinical trials. Urology, 48: 398, 1996 3. McConnell, J. D., Barry, M. J., Bruskewitz, R. C. et al: Clinical Practice Guideline. Benign Prostatic Hyperplasia: Diagnosis and Treatment. Benign Prostatic Hyperplasia Guideline Panel. Rockville, Maryland: Agency for Health Care Policy and Research, 1994. 4. Koyanagi, T., Artibani, W., Correa, R. et al: Initial diagnostic evaluation of men with lower urinary tract symptoms. Presented at the 4th International Consultation on Benign Prostatic Hyperplasia (BPH), Paris, France, July 2–5, 1997 5. Oesterling, J. E., Martin, S. K., Bergstralh, E. J. et al: The use of prostate specific antigen in staging patients with newly diagnosed prostate cancer. JAMA, 269: 57, 1993 6. Gleave, M. E., Coupland, D., Drachenberg, D. et al: Ability of serum prostate-specific antigen levels to predict normal bone scans in patients with newly diagnosed prostate cancer. Urology, 47: 708, 1996 7. Charpak, Y., Blery, C., Chastang, C. et al: Prospective assessment of a protocol for selective ordering of preoperative chest x-rays. Can J Anaesth 35: 259, 1988 8. Prostate Cancer Trialists’ Collaborative Group: Maximum androgen blockade in advanced prostate cancer: an overview of 22 randomised trials with 3283 deaths in 5710 patients. Lancet, 346: 265, 1995 9. Eisenberger, M. A., Blumenstein, B. A., Crawford, E. D. et al: Bilateral orchiectomy with or without flutamide for metastatic prostate cancer. New Engl J Med, 339: 1036, 1998 10. Goldenberg, S. L., Bruchovsky, N., Gleave, M. E. et al: Intermittent androgen suppression in the treatment of prostatic carcinoma: an update. J Urol, suppl., 157: 333, abstract 1302, 1997