Trends in Diagnosis and Disparities in Initial Management of High-Risk Prostate Cancer in the US

[pjoshea13]

New study below [1] & [2].

"The proportional rates of high-risk prostate cancer increased from 11.8% to 20.4%"

"Prostatectomy rates increased from 22.8% in 2004 to 40.5% in 2016, nearly equaling radiotherapy rates by 2016. Randomized data comparing modalities do not and likely will not exist in the foreseeable future to determine optimal treatment." [1]

The paper makes it seem that the treatment decision is basically irrational.

"Several factors increased the odds of prostatectomy, including higher income and education, treatment at an academic center, and having private insurance." [2]

-Patrick

[1] jamanetwork.com/journals/ja...

August 31, 2020

Trends in Diagnosis and Disparities in Initial Management of High-Risk Prostate Cancer in the US

Vishesh Agrawal, MD1; Xiaoyue Ma, MSci2; Jim C. Hu, MD, MPH3; et al Christopher E. Barbieri, MD, PhD3; Himanshu Nagar, MD1

Author Affiliations Article Information

JAMA Netw Open. 2020;3(8):e2014674. doi:10.1001/jamanetworkopen.2020.14674

Introduction

Evidence suggests increasing rates of high-risk prostate cancer. Treatment for high-risk prostate cancer includes prostatectomy or radiotherapy. We examine trends in proportional diagnosis rates and management of patients with high-risk prostate cancer.

Methods

The National Cancer Database (NCDB) tabulates data from more than 70% of new cancer diagnoses across the US. The NCDB was queried to identify men with high-risk prostate cancer from 2004 to 2016. Men were classified as having high-risk disease if they had clinical stage T3-T4, a prostate-specific antigen level greater than 20 ng/mL, or a Gleason score of 8-10. The eFigure in the Supplement outlines the cohort selection.

Descriptive statistics for factors were reported as frequency. The Cochran-Armitage test identified trends in treatment with time. Multivariable logistic regression examined factors associated with each treatment. All tests were 2-sided and considered significant at an α level of .05. Analyses were performed with SAS software version 9.4 (SAS Institute Inc). This study follows STROBE reporting guidelines.

Results

Overall, 214 972 men were identified as having high-risk prostate cancer from 2004 to 2016 and 75 847 underwent prostatectomy and 104 635 underwent radiotherapy. White and black men comprised 79.2% and 16.1% of the cohort, respectively. Government-based insurance was used by 59.3% of the men. Approximately 82% of the cohort had a Charlson-Deyo comorbidity index of 0.

The proportional rates of high-risk prostate cancer increased from 11.8% to 20.4% (P < .001). The proportion of men undergoing prostatectomy increased from 22.8% to 40.5% (P < .001; Figure, A). Conversely, the rates of radiotherapy decreased from 59.7% to 43.3% (P < .001). External beam radiation therapy (EBRT) with a brachytherapy boost was used in 12.6% of men undergoing radiotherapy. Consistent with data presented in part A of the Figure, the odds of undergoing prostatectomy increased from 2004 to 2013 and remained consistent through 2016 (odds ratio, 2.34 [95% CI, 2.12-2.48]; P < .001). This trend was also observed among black men (Figure, B). The multivariable analysis appears in the Table.

Discussion

Prostatectomy rates increased from 22.8% in 2004 to 40.5% in 2016, nearly equaling radiotherapy rates by 2016. Randomized data comparing modalities do not and likely will not exist in the foreseeable future to determine optimal treatment. The ProtecT trial compared prostatectomy vs radiotherapy and showed no difference in prostate-cancer specific mortality, but did not include a significant number of patients with high-risk prostate cancer.1 The Prostate Advances in Comparative Evidence trial (NCT01584258) compares prostatectomy vs radiotherapy, but only includes patients with low-risk and intermediate-risk cancer.

Population-based and institutional studies report conflicting results. Boorjian et al2 showed improved all-cause mortality with prostatectomy compared with EBRT. Kishan et al3 reported improved prostate-cancer specific mortality among men with Gleason score 9-10 treated with EBRT and a brachytherapy boost vs EBRT or prostatectomy; there was no difference between EBRT and prostatectomy. Our study showed limited use of the brachytherapy boost in patients with high-risk disease.

The increase in prostatectomies may reflect increasing acceptance of population-based data suggesting superiority of prostatectomy.2 The increasing use of robotic approaches suggests urologists and patients may regard prostatectomies safer than previous techniques. Conversely, a decrease in radiotherapy may reflect reluctance toward recommended androgen deprivation therapy with radiotherapy.

Demographic and socioeconomic factors were associated with treatment selection for patients with high-risk prostate cancer. Black men were less likely than white men to undergo prostatectomy, which is consistent with previous studies, but our findings suggest this gap has improved over time.4 Men with private insurance were more likely to undergo prostatectomy. Higher income, private insurance, and treatment at an academic facility were found to be associated with use of robotic prostatectomy.5 Thus, the differential use of prostatectomy may reflect limited access to high-volume centers and disproportionate reimbursement for robotic techniques.

Men may prefer prostatectomy given the treatment burden of radiotherapy, which may change with shortened schedules.6 Prostatectomy rates have doubled since 2004 without guideline evidence suggesting its superiority. Trials are needed to guide optimal care. The findings of this study are limited by its retrospective nature.

***

[2] medpagetoday.com/hematology...

Surgery Rates Doubled for High-Risk Prostate Cancer

— Use of prostatectomy nearly equaled radiotherapy in 2016

by Ian Ingram, Deputy Managing Editor, MedPage Today August 31, 2020

As the rates of high-risk prostate cancer in the U.S. increased in recent years, use of prostatectomy nearly doubled while radiotherapy declined, new research from the National Cancer Database (NCDB) found.

From 2004 to 2016, the proportion of prostate cancer cases classified as high risk increased from 11.8% to 20.4%, and use of prostatectomy in this population rose from 22.8% to 40.5% during this time (P<0.001 for both), according to Himanshu Nagar, MD, a radiation oncologist at Weill Cornell Medicine in New York City, and colleagues.

This increase in surgery was met with declines in radiotherapy use for high-risk patients, which fell from 59.7% to 43.3% over this stretch of time (P<0.001), the group reported in JAMA Network Open.

These shifts in treatment patterns have taken place without guideline evidence suggesting superiority of prostatectomy, Nagar's group noted.

"The increasing use of robotic approaches suggests urologists and patients may regard prostatectomies safer than previous techniques," the authors wrote. "Conversely, a decrease in radiotherapy may reflect reluctance toward recommended androgen deprivation therapy with radiotherapy."

From 2004 to 2013, the likelihood that a patient would receive prostatectomy increased, and then held steady through 2016 (OR 2.34, 95% CI 2.12-2.48, P<0.001). This increase was observed regardless of race, though Black men were still less likely to undergo surgery across the study period (OR 0.57, 95% CI 0.55-0.59, P<0.001).

Several factors increased the odds of prostatectomy, including higher income and education, treatment at an academic center, and having private insurance. Conversely, higher Gleason score, disease stage, prostate-specific antigen (PSA) levels, and age, as well as living in a rural area all reduced the odds of undergoing surgery.

Radiotherapy and prostatectomy are both standard options for men with high-risk prostate cancer -- defined as clinical stage T3-T4, high Gleason scores (8-10), or PSA levels over 20 ng/mL. Comparisons of the two approaches have shown conflicting results in single-center studies, though some population-based analyses have favored surgery.

A study in Gleason 9-10 tumors showed improved prostate cancer-specific mortality with external-beam radiation therapy (EBRT) plus a brachytherapy boost versus surgery or EBRT alone, but no difference between surgery and EBRT alone. In the current analysis, few patients received a brachytherapy boost.

"Randomized data comparing modalities do not and likely will not exist in the foreseeable future to determine optimal treatment," the authors wrote. "The ProtecT trial compared prostatectomy vs radiotherapy and showed no difference in prostate-cancer specific mortality, but did not include a significant number of patients with high-risk prostate cancer."

Similarly, the ongoing PACE (Prostate Advances in Comparative Evidence) trial is restricted to low- or intermediate-risk prostate cancer.

[noahware]

"The paper makes it seem that the treatment decision is basically irrational"

I don't know if "irrational" is the right word, but I suspect many factors come into play in making that decision. But here is how it must likely go for many (and nearly went for me): dx is made by a urologist, who is either a surgeon or works with a surgeon/surgery practice, and he/they generate the most income from surgery, and he suggests -- surprise -- surgery!

From a patient perspective: I have a malignant tumor, and you want to REMOVE it from my body? Sooner rather than later? Yes!

Or... you DON'T want to cut me open in a major surgery with major risks, and instead I could just have invisible and not-too-painful rays target the tumor and kill it without going under the knife? Yes!

That's all pretty rational, from both sides.

[pjoshea13 in reply to noahware]

But the dynamics seem to have changed - in spite of "The Invasion of the Prostate Snatchers" (2010) by Mark Scholz & Ralph Blum. A big variable is the availability of robotic surgery. It takes a lot longer to master, but men might feel that it is safer?

-Patrick

[Concernedwife24]

What I wonder is why have the rates of aggressive cancers gone up so much?

[pjoshea13 in reply to Concernedwife24]

The U.S. Preventive Services Task Force "is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine" but includes no urologists & no oncologists.

First they recommended that men aged 70 & up not be screened. The assumption being that most will not live more than 10 years, even though the life expectancy at age 70 is 14.39 years

Subsequently, they recommended that no man at all be screened - not even a DRE.

Later, they softened that by saying that concerned men should talk with their doctors, but they added this:

"Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction."

The message to American men was received and while fewer are diagnosed with Gleason 3+3, more are diagnosed at a later stage. Many unscreened men do not know they have PCa until they experience bone pain.

-Patrick