Impact of Treating Physician on Radiation Therapy Related Severe Toxicities in Men with Prostate Cancer

Purpose: The impact of treating physician on radiation therapy (RT) related toxicity is unclear. We carried out a secondary analysis of a randomized controlled study to determine whether the risk of RT-related late toxicities in patients with prostate cancer varies depending on the treating radiation oncologist. Methods and Materials: This is a secondary analysis of a phase 3 randomized controlled study in which patients with prostate cancer with Gleason score <7, clinical stage T1b-T3a, and prostate-specific antigen <30 ng/mL were randomized to receive androgen suppression for 6 months, starting either 4 months before or concurrently with definitive prostate radiation therapy. Incidence of late RT-related toxicity was estimated using Kaplan -Meier methods. We applied multivariable semiparametric shared frailty models with gamma distribution to determine the between-physician variation in the hazard of late RT-related grade >3 gastrointestinal, genitourinary, or overall toxicity. Patient level covariables included age, risk group, year of enrollment, and treatment regimen. Frailty variance, a measure of unexplained heterogeneity, was estimated with 95% confidence intervals (CIs). Statistical significance was suggested when the lower limit of the 95% CI for the frailty variance was >0. The Commenges-Andersen test was used for P value estimation. Results: Overall, 426 patients were treated by 9 radiation oncologists. On log-rank test, there was a significant difference in the cumulative incidence of overall grade >= 3 toxicities (P = .001) and grade >= 3 gastrointestinal toxicity (P = .01) among the physician based clusters. The frailty variance for overall late grade >= 3 toxicity was 0.31 (95% CI, 0.02-1.39; P = .01). The frailty variance for the grade >= 3 gastrointestinal and genitourinary toxicity was 0.84 (95% CI, 0.00-4.20; P = .11) and 0.11 (95% CI, 0.00-1.13; P = .31), respectively. Conclusions: In our study, the hazard of overall RT-related late grade >= 3 toxicity varied significantly depending on treating radiation oncologist. Further studies are required to explore the underlying processes that lead to such variations in clinical trials involving radiation therapy in prostate cancer. (C) 2020 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.