Case volume and outcomes after brachytherapy

It has been well known for a while now that, as far as radical prostatectomy is concerned, surgeons with a high case volume tend to have better overall outcomes with a lower incidence of adverse effects than the average. A recent paper by Chen et al. has made an initial attempt to determine whether the same effects are evident with respect to brachytherapy. And the answer is not entirely positive — but there are limitations to this study.

Chen et al. based their study claims submitted to Medicare-enrolled men older than 65 years living in SEER surveillance areas who were diagnosed with prostate cancer from 1991 to 1999 and underwent brachytherapy as initial treatment. Case volume was calculated for each physician and hospital from 1991 to 2001. Outcomes of interest were recurrence, prostate cancer death, all deaths, and 2-year complications. As a consequence, we immediately have to recognize three things:

  • This is a retrospective analysis and quality of the study results are highly dependent on the quality of the data available.
  • The study is limited to Medicar enrollees living in selected areas of the country (the ones for which SEER data are available).
  • Brachytherapy was in a state of major evolution and improvement from 1991-1999 and so these data should not be considered to represent the quality of outcomes now available.

So what did the study find?

  • There were 5,595 men whose tretament could be appropriately assessed.
  • Men who were older, non-Caucasian, of lower income, unmarried, living in nonurban areas or had more comorbidities were more likely to see physicians who did fewer procedures
  • There was no association between physician volume and complication rate 2 years after brachytherapy.
  • The combination of diagnosis of complications and procedures to address the complications was slightly lower at high volume hospitals.
  • Patients treated by higher volume physicians had a statistically significant, lower rates of recurrence and of prostate cancer death, with a borderline significant decrease in all deaths.
  • There was no significant association between hospital volume and recurrence, prostate cancer death, or all deaths.

The authors conclude that (within the limitations of the study), men treated with brachytherapy by higher volume physicians were at lower risk for recurrence and prostate cancer death, and showed a borderline decrease in total deaths but that there was no clear relationship between provider volume and complications following treatment.

Thye “New” Prostate Cancer InfoLink would suggest that while this is an important, initial attempt to explore the relationship between provider volume and outcomes to brachytherapy, the results are highly influenced by the limitations inherent in the available data. It may be as much as another decade before we can really know whether brachytherapy provider volume actually affects post-treatment complications.

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