A growing set of low-risk cancers, including early-stage thyroid and kidney cancers, is associated with excellent outcomes regardless of management strategy. Given the risks associated with overtreatment of these cancers, it follows that many patients should be treated nonoperatively.
Treatment guidelines have changed accordingly. The National Comprehensive Cancer Network endorsed surveillance of thyroid cancer in 2015, and the American Urological Association did the same for kidney cancer in 2017. And yet, overall rates of nonoperative management of both cancers remain stubbornly low. The question is, why?
A study published in JAMA Network Open in November 2022 explored the hypothesis that hospital and health-system factors would point toward an explanation. In their combined analysis, the authors identified 19,570 individuals with low-risk thyroid cancer and 41,403 individuals with small kidney masses across 262 hospitals. They found evidence that hospitals and health systems are indeed associated with choices for nonoperative management in these low-risk malignant neoplasms.
“By far the biggest thing that this paper highlights is the stark difference at the level of the hospital,” says corresponding author Alexander Putnam Cole, MD, associate surgeon in the Brigham and Women’s Hospital Division of Urology. “Which hospital you get treated at makes a huge difference in whether you’re offered newer, less intensive approaches, including surveillance, for these types of cancers.”
A Call for Greater Standardization of Care
Dr. Cole devotes much of his practice to exploring less invasive treatments for cancers, particularly active surveillance and minimally invasive, image-guided treatments for prostate cancer. In addition, he conducts research to understand the economic, cultural, health-system, and other factors that influence clinicians’ treatment decisions.
He notes that patient-specific factors (e.g., age, comorbidity scores) and disease-specific factors (e.g., stage, grade, location of cancer in the body) help determine whether an individual receives a less aggressive treatment. But those factors don’t tell the whole story.
“We wanted to focus on the hospital’s role in these decisions,” Dr. Cole says. “The economics of health care in the U.S. are such that in many types of practices, you’re paid more for doing more surgery. So payment models are most obvious culprit for this variability, but other factors could come into play as well—the fear of getting sued, departmental practice, institutional culture, familiarity with new treatment guidelines, availability of imaging, etc.”
The study authors found that 2.1% of patients with low-risk thyroid cancer and 9.5% of patients with kidney cancer, respectively, received nonoperative management. Furthermore, they identified significant between-hospital variability in nonoperative management when controlling for both patient and disease variables:
- From 1.1% in the bottom decile to 10.3% in the top decile for thyroid cancer
- From 4.3% in the bottom decile to 24.6% in the top decile for small kidney masses
“On the whole, if it’s safe not to do surgery, that’s something we should pursue,” Dr. Cole says. “The amount of variability we saw among patients who ostensibly have the same suitability for nonoperative management shows a lack of standardization of care. But that’s something we should strive for because standardized care tends to be of higher quality, more measurable, and more equitable.”
Getting to the Heart of Why Treatment Decisions Are Made
It is imperative, Dr. Cole argues, to root out those factors that inappropriately influence treatment decisions. For instance, the study reaffirmed that female sex, low income, and Black race are all associated with less aggressive treatment.
The study authors also aimed to uncover health system-based variables in the treatment of thyroid and kidney cancers. “We wanted to look at whether the same institutions that are doing nonoperative management of one disease are also doing it for the other,” Dr. Cole says. “And if they are, that would tell us something about the health system that’s encouraging surgeons to act in this way.”
Ultimately, Dr. Cole and his co-authors found a weak to minimal correlation of nonoperative management in thyroid and kidney cancers within hospitals. He says that although the correlation is not strong, it does deliver a crucial insight: When combined with the extreme between-hospital variability, it provides evidence that some health systems are associated with less-intensive management strategies across disciplines and diseases.
“Finding those health-system factors that affect multiple disciplines and multiple diseases could be very impactful,” he says. “There are many surgical services out there that are more intensive or less intensive—doing knee replacements instead of physical therapy, doing cardiac stents instead of medical management of coronary artery disease—and that’s what we’re getting at with this sort of a study.”
Dr. Cole hopes further research will shed more light on hospital-level factors shaping choices about management of low-risk cancers. But health care professionals shouldn’t wait any longer to evaluate how they approach this issue. As the University of Pennsylvania’s Daniel S. Roberson, MD, and Phillip M. Pierorazio, MD, wrote in an invited commentary on the study, “Individual clinicians must be aware of outside influences to best account for them. Equally, if not more importantly, institutions cannot shift all responsibility to physicians when policies and incentive-based systems influence the care of patients.”