Dataset Information

Androgen deprivation therapy for prostate cancer: Prescribing behaviors and preferences among urologists.

ABSTRACT:

Introduction

Several androgen deprivation therapy (ADT) medications are available for treating advanced prostate cancer with roughly equivalent oncological efficacy and tolerability. We investigated the proportion of physicians who predominantly prescribe one type of ADT drug ("mono-prescriber") and assessed characteristics associated with prescription behavior.

Methods

Ontario men aged ≥65 years who were diagnosed with advanced prostate cancer (1997-2017) and initiated ADT thereafter for ≥3 consecutive months were identified using population-level administrative data. Their first prescription for injectable ADT was linked to a physician, and urologists with ≥10 prescriptions over the study period were included in the analysis (n=282). Urologists were classified as high mono-prescribers if ≥80% of their prescriptions were for one drug type. Multivariable logistic regression was used to examine the association of physician characteristics with the odds of being a high mono-prescriber.

Results

Overall, 67 (23.8%) of urologists were classified as high mono-prescribers but the frequency varied across health planning regions. The most commonly prescribed drugs and those used by mono-prescribers were goserelin (41.8% and 56.7%) and leuprolide (44.3% and 43.3%), respectively. In multivariable analysis, the odds of a physician being a high mono-prescriber were higher with more years in practice (odds ratio [OR] 1.06/year, 95% confidence interval [CI] 1.03-1.09, p<0.0001) and lower for higher patient volume (OR 0.33 for above vs. below median, 95% CI 0.17-0.63, p=0.0008).

Conclusions

Overall, one in four urologists were classified as high mono-prescribers. Mono-prescribers had more years in practice and smaller volume practices, potentially suggesting habitual prescription behavior and/or the effect of external pressures.

SUBMITTER: Cheung DC

PROVIDER: S-EPMC9565067 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

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Publications

Androgen deprivation therapy for prostate cancer: Prescribing behaviors and preferences among urologists.

Cheung Douglas C DC Martin Lisa J LJ Alibhai Shabbir M H SMH Komisarenko Maria M Dharma Christoffer C Niu Yue Y Warde Padraig P Sridhar Srikala S SS Fleshner Neil E NE Kulkarni Girish S GS Finelli Antonio A

Canadian Urological Association journal = Journal de l'Association des urologues du Canada 20221001 10

<h4>Introduction</h4>Several androgen deprivation therapy (ADT) medications are available for treating advanced prostate cancer with roughly equivalent oncological efficacy and tolerability. We investigated the proportion of physicians who predominantly prescribe one type of ADT drug ("mono-prescriber") and assessed characteristics associated with prescription behavior.<h4>Methods</h4>Ontario men aged ≥65 years who were diagnosed with advanced prostate cancer (1997-2017) and initiated ADT therea ...[more]

PMID: 35621292

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Project description:ObjectivesTo understand how best to further reduce the inappropriate use of pre-surgical androgen deprivation therapy (ADT), we investigated the determinants (influences) of ADT prescribing in urologists in two European countries using an established behavioural science approach. Additionally, we sought to understand how resource limitations caused by COVID-19 influenced this practice. Identification of key determinants, of undistributed and disrupted practice, will aid development of future strategies to reduce inappropriate ADT prescribing in current and future resource-limited settings.Participants and methodsWe conducted semi-structured qualitative interviews with urologists practicing in Italy and the UK from February to July 2022. Interviews focussed on undisrupted (usual) practice and disrupted practice (changes made during COVID-19 restrictions). Codes were generated inductively and were mapped to the 14 domains of the Theoretical Domains Framework. Relevant domains of influence were identified, and the similarities and differences between the UK and Italy were distinguished.ResultsWe identified 10 domains that were influential to ADT prescribing in the UK and eight in Italy. The role of guidance and evidence, the cancer care setting, the patients and the urologist's beliefs and experiences were identified as areas that were influential to ADT prescribing before surgery. Twenty-one similarities and 22 differences between the UK and Italy, for usual and COVID-19 practice, were identified across these 10 domains.ConclusionSimilarities and differences influencing ADT prescribing prior to surgery should be considered in behavioural strategy development and tailoring to reduce inappropriate ADT use. We gained an understanding of usual, undistributed care and resource-limited or disrupted care due to COVID-19 in two European countries. This gives an indication of how influences on ADT prescribing may change in future resource-limited circumstances and where efforts can be focused now and in future.

Project description:Background. For men with intermediate-risk prostate cancer (IRPC), adding short-term androgen deprivation therapy (ADT) to external beam radiation therapy (EBRT) has shown efficacy, but men are often reluctant to accept it because of its impact on quality of life. Methods. We conducted time tradeoffs (score of 1 = perfect health and 0 = death) and probability tradeoffs with patients aged 51 to 78 y who had received EBRT for IRPC within the past 2 y. Of 40 patients, 20 had received 6 mo of ADT and 20 had declined. Utility assessments explored 4 ADT-related side effects: hot flashes, fatigue, loss of libido/erectile dysfunction, and weight gain. Results. The most commonly reported "worst" treatment-related complication of ADT was fatigue (50% in both cohorts) followed by reduced libido/erectile dysfunction (40% in both cohorts). The utilities for fatigue were mean = 0.71 and median = 0.92 and for reduced libido/erectile dysfunction were mean = 0.81 and median = 0.92. Utilities did not differ significantly between cohorts. Assuming a 6-mo course of ADT, men reported being willing to trade 3 mo of life expectancy to avoid fatigue due to ADT and 1.8 mo to avoid sexual side effects. Patients in the ADT cohort were willing to accept the side effects of ADT in exchange for a mean 8% absolute increase in survival, whereas patients in the no ADT cohort required a 16% increase (P < 0.001). Conclusions. When considering treatment with ADT, men with IRPC identified fatigue and sexual dysfunction as the most bothersome side effects. Patients who declined ADT expected a larger survival benefit than those who opted for treatment. Both groups expected a survival benefit exceeding that shown by recent trials, suggesting some men may be selecting treatments inconsistent with their preferences.HighlightsThis study demonstrates that prostate cancer patients receiving radiation therapy are reluctant to receive androgen deprivation therapy (ADT) most commonly due to anticipated fatigue and loss of libido/erectile dysfunction.Men who had received ADT reported they would require an average 8% absolute increase in survival to tolerate its side effects, whereas those who declined ADT would require an average 16% increase.Required thresholds are well above the estimated absolute survival benefit for ADT demonstrated in recent clinical trials, suggesting an unmet need for improved patient education regarding the risks and benefits of ADT.

Project description:ContextAndrogen deprivation therapy (ADT) for prostate cancer (PCa) represents one of the most effective systemic palliative treatments known for solid tumors. Although clinical trials have assessed the role of ADT in patients with metastatic and advanced locoregional disease, the risk-benefit ratio, especially in earlier stages, remains poorly defined. Given the mounting evidence for potentially life-threatening adverse effects with short- and long-term ADT, it is important to redefine the role of ADT for this disease.ObjectiveReview the published experience with currently available ADT approaches in various contemporary clinical settings of PCa and reported serious treatment-related adverse events. This review addresses the level of evidence associated with the use of ADT in PCa, focusing upon survival outcome measures. Furthermore, this paper discusses evolving approaches targeting androgen receptor signaling pathways and emerging evidence from clinical trials with newer compounds.Evidence acquisitionA comprehensive review of the literature was performed, focusing on data from the last 10 yr (January 2000 to July 2011) and using the terms androgen deprivation, hormone treatment, prostate cancer and adverse effects. Abstracts from trials reported at international conferences held in 2010 and 2011 were also evaluated.Evidence synthesisData from randomized controlled trials and population-based studies were analyzed in different clinical paradigms. Specifically, the role of ADT was evaluated in patients with nonmetastatic disease as the primary and sole treatment, in combination with radiation therapy (RT) or after surgery, and in patients with metastatic disease. The data suggest that in men with nonmetastatic disease, the use of primary ADT as monotherapy has not shown a benefit and is not recommended, while ADT combined with conventional-dose RT (<72Gy) for patients with high-risk disease may delay progression and prolong survival. The postoperative use of ADT remains poorly evaluated in prospective studies. Likewise, there are no trials evaluating the role of ADT in patients with biochemical relapses after surgery or RT. In patients with metastatic disease, there is a clear benefit in terms of quality of life, reduction of disease-associated morbidity, and possibly survival. Treatment with bilateral orchiectomy, luteinizing hormone-releasing hormone agonist therapy, with and without antiandrogens has been associated with various serious adverse events, including cardiovascular disease, diabetes, and skeletal complications that may also affect mortality.ConclusionsAlthough ADT is an effective treatment of PCa, consistent long-term benefits in terms of quality and quantity of life are predominantly evident in patients with advanced/metastatic disease or when ADT is used in combination with RT (<72Gy) in patients with high-risk tumors. Implementation of ADT should be evidence based, with special consideration to adverse events and the risk-benefit ratio.

Dataset Information

Androgen deprivation therapy for prostate cancer: Prescribing behaviors and preferences among urologists.

Introduction

Methods

Results

Conclusions

Publications

Androgen deprivation therapy for prostate cancer: Prescribing behaviors and preferences among urologists.

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