Variation in prostate cancer care.

The use of many medical and surgical therapies varies widely between clinicians and geographic regions. Perhaps nowhere is this more evident than in the treatment of men with early-stage prostate cancer. For this group of patients, there is substantial variation not only in the use of any local therapy (vs observation), but also in the use of specific treatmentmodalities. The former concern is particularly salientamongmenwith low-riskprostatecancer, agroupfor whom the survival benefits of local therapy are less clear, while the potential adverse effects, including urinary and sexual dysfunction, may be no less apparent. Because surgery and radiationmay represent overtreatment for some men with low-grade tumors, several clinical guidelinesnowrecommend initial observation (usually in the form of active surveillance) for patients with low-risk disease.1 In a recent article from JAMA Internal Medicine, Hoffman and colleagues2 examined the use of observation vs local therapy for men with prostate cancer, with an emphasis on understanding whether the patient or physician has a greater influence on this initial treatment choice. In a well-designed study based on data from SEER, Medicare, and the American Medical Association Physician MasterFile, the authors reported that among more than 12 000 patients diagnosed with low-risk prostate cancer from 2006 through 2009, only 20% underwent observation. Moreover, definitive treatment (mainly radiation therapy) was used by 70% and 55% of men aged 76 to 80 years and older than 80 years, respectively, patients for whom the benefits of treatment are most uncertain. JAMA INTERNALMEDICINE