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POLICY UPDATE: JOINT STATEMENT BY MEMBERS OF THE NATIONAL COMPREHENSIVE CANCER NETWORK PROSTATE CANCER GUIDELINES PANEL

Delivered on behalf of NCCN on October 24, 2013 by James L. Mohler, MD, Roswell Park Cancer Institute, Chair of the NCCN Prostate Cancer Guidelines Panel

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 today’s 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 in 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. 

Today’s study supports 1) the report by the Government Accountability Office on self-referral, which provided evidence of over-treatment 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
  • 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 over-treatment or under-treatment.   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.

 

           NCCN Prostate Cancer Panel Members

Panel Member Name

Specialty

Institutional Affiliation

James L. Mohler, MD/Chair

Urology

Roswell Park Cancer Institute

Philip W. Kantoff, MD/Vice-Chair

Medical Oncology

Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center

Andrew J. Armstrong, MD, ScM

Medical Oncology

Duke Cancer Institute

Robert R. Bahnson, MD

Urology

The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

Michael Cohen, MD

Cytopathology, Pathology

Huntsman Cancer Institute at the University of Utah

Anthony Victor D’Amico, MD, PhD

Radiotherapy/Radiation Oncology

Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center

James A. Eastham, MD

Urology

Memorial Sloan-Kettering Cancer Center

Charles A. Enke, MD

Radiotherapy/Radiation Oncology

Fred & Pamela Buffett Cancer Center at The Nebraska Medical Center

Thomas A. Farrington, BSEE

Patient Advocate

Prostate Health Education Network (PHEN)

Celestia S. Higano, MD, FACP

Urology, Medical Oncology

Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance

Eric Mark Horwitz, MD

Radiotherapy/Radiation Oncology

Fox Chase Cancer Center

Christopher J. Kane, MD, FACS

Urology

UC San Diego Moores Cancer Center

Mark H. Kawachi, MD

Urology

City of Hope Comprehensive Cancer Center

Michael Kuettel, MD, MBA, PhD

Radiotherapy/Radiation Oncology

Roswell Park Cancer Institute

Richard J. Lee, MD, PhD

Medical Oncology

Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center

Arnold W. Malcolm, MD, FACR

Radiotherapy/Radiation Oncology

Vanderbilt-Ingram Cancer Center

David Miller, MD, MPH

Urology

University of Michigan Comprehensive Cancer Center

Elizabeth R. Plimack, MD,
MS

Medical Oncology

Fox Chase Cancer Center

Julio M. Pow-Sang, MD

Urology

Moffitt Cancer Center

Sylvia Richey, MD

Medical Oncology

St. Jude Children’s Research Hospital/University of Tennessee Health Science Center

Mack Roach, III, MD

Radiotherapy/Radiation Oncology

UCSF Helen Diller Family Comprehensive Cancer Center

Eric Rohren, MD, PhD

Diagnostic/Interventional Radiology

The University of Texas MD Anderson Cancer Center

Stan Rosenfeld

Patient Services Committee
Chair/Patient Advocate

University of California San Francisco

Eric J. Small, MD

Medical Oncology, Urology

UCSF Helen Diller Family Comprehensive Cancer Center

Guru Sonpavde, MD

Medical Oncology

University of Alabama at Birmingham Comprehensive Cancer Center

Sandy Srinivas, MD

Medical Oncology

Stanford Cancer Institute

Cy Stein, MD, PhD

Medical Oncology

City of Hope Comprehensive Cancer Center

Seth A. Strope, MD, MPH

Urology

Siteman Cancer Center at Barnes- Jewish Hospital and Washington University School of Medicine

Jonathan Tward, MD, PhD

Radiotherapy/Radiation Oncology

Huntsman Cancer Institute at the University of Utah

Patrick C. Walsh, MD

Urology

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 25 of the world’s leading cancer centers, is dedicated to improving the quality, effectiveness, and efficiency of care provided to patients with cancer. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers. The primary goal of all NCCN initiatives is to improve the quality, effectiveness, and efficiency of oncology practice so patients can live better lives.  Visit NCCN.org for more information.