New US national prostate cancer data classified by NCCN risk category


Prior to 2013, when the National Cancer Institute released accumulated, de-identified, prostate cancer-specific patient data from the national SEER cancer registry, those data only included the post-surgical, pathological Gleason scores and not the biopsy Gleason scores.

Pathological Gleason scores have been captured in the SEER data since 2004. However, in 2010 SEER started to capture biopsy-related Gleason scores, and the first set of data to include those biopsy-related Gleason scores (for the year 2010) were released in 2013.

Mahmood et al. have now published the first set of data to give an accurate assessment of prostate cancer presentation and treatment based on a complete set of clinical factors at the time of diagnosis (i.e., inclusive of patient age, race/ethnicity, marital status, place of diagnosis, clinical stage, PSA level, biopsy Gleason score, and initial management).

These data allowed Masood et al. to assign an NCCN risk level (i.e., low, intermediate, or high risk) to the majority of patients with a diagnosis of prostate cancer in 2010 who were captured by the SEER registry system (which encompasses some 28 percent of all the American population).

Here is what they found:

  • 54,537 men were diagnosed with prostate cancer in 2010 and included in the SEER database.
    • 48,978 men (89.8 percent) had localized prostate cancer.
    • 2,655 men (4.7 percent) had nodal or distant metastasis.
    • 2,904 men (5.3 percent) could not be classified.
    • Sufficient data for assignment of NCCN risk was available for 42,403 men (77.8 percent).
    • There was insufficient data to assign NCCN risk for 12,134 men (22.2 percent).
  • Average (median) age at diagnosis was 65 years.
  • Racial/ethnic breakdown of the 42,403 patients who could be risk-classified indicated that
    • 29,266 men (69.0 percent) were white/Caucasian.
    • 6,291 men (14.8 percent) were black/African American.
    • 3,400 men (8.0 percent) were Hispanic.
    • 1,884 men (4.4 percent) were Asian or Pacific Islander.
    • 143 men (0.3 percent) were Native American.
  • The NCCN risk distribution of the 42,403 classifiable patients indicated that
    • 16,171 men (38.1 percent) were low risk.
    • 16,990 men (40.0 percent) were intermediate risk.
    • 9,242 men (21.8 percent) were high risk.
  • 66 percent of the 42,403 risk-classifiable patients had non-plapable (clinical stage T1c) prostate cancer.
  • Of the 7,882 risk-classifiable patients with clinical stage T2 disease
    • 2,721 men (34.5 percent) were low risk.
    • 2,982 men (37.8 percent) were intermediate risk.
    • 2,179 men (27.6 percent) were high risk.
  • Biopsy Gleason score was the primary driver of risk assignment.
    • 84 percent of men with intermediate-risk disease had a biopsy Gleason score of 7.
    • 71 percent of men with high-risk disease had a biopsy Gleason score of 8 to 10.
  • The incidence of high-risk disease was associated with race and with age.
    • Non-white patients of all types were at higher risk that white patients for high-risk prostate cancer.
    • 40.3 percent of men diagnosed at 75 years and older had high-risk disease (compared to 21.7 percent of men aged between 65 and 75 and 16.3 percent of men between 55 and 65).
  • Initial management could be determined for 38,634/42,403 men with classifiable disease.
    • 8,832/38,634 men (22.9 percent) received no local treatment.
    • 15,421/38,634 men (39.9 percent) received a radical prostatectomy.
      • 694/15,421 prostatectomy patients (4.5 percent) also received immediate, adjuvant radiation therapy.
    • 13,855/38,634 men (35.9 percent) received radiation therapy.
    • About another 1 percent of men received some other form of “local tumor destruction”.
  • Local first-line treatment varied by race/ethnicity, by age, and by NCCN risk.
    • White patients were most likely to receive a radical prostatectomy (42.3 percent).
    • Black patients were most likely to be treated with radiation therapy (42.5 percent).
    • Men aged from 55 to 65 years were most likely to receiev a radical prostatectomy (53.7 percent).
    • Men > 75 were most likely to be treated with radiation therapy (49.1 percent) or to have no immediate localized treatment (42.4 percent).
    • Men with NCCN low-risk disease were most likley to receive a radical prostatectomy (39.9 percent).
    • Men with NCCN high-risk disease were most likely to be treated with radiation therapy (43.0 percent).
  • Men who were older, non-white, unmarried, or living in a county with a higher poverty rate were more likely than others to be diagnosed with high-risk disease.
  • Men who were older, black, unmarried, or living in a county with a higher poverty rate were less likely than others to receive any form of local treatment.

Mahmood et al. are also careful to point out what is not captured by the SEER database:

  • We do not know what percentages of these patients had received any PSA tests for risk of prostate cancer prior to their actual diagnosis.
  • We do not know how men who received no local therapy were actually treated (i.e., whether they were on active surveillance or watchful waiting or whether they received immediate androgen deprivation therapy of some type).
  • We do not know why local therapy was withheld for specific patients (e.g., because the patient already had a very short life expectancy or because he simply refused treatment).

From the perspective of The “New” Prostate Cancer InfoLink, if there is anything surprising in these data, it is that more men are still being diagnosed with intermediate-risk disease (40.0 percent) than with low-risk disease (38.1 percent). This may (but may not) reflect the high percentage of men who still just don’t do much to monitor their health issues until they have clear symptoms of a problem.

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