In 2004-07 most Medicare-eligible men were getting radiation therapy for first-line treatment of prostate cancer

In a second article in the new journal JAMA Oncology, researchers at the University of California Los Angeles suggest that 58 percent of all relatively recent treatment for prostate cancer was being given by radiation therapy of some type, and that indolent prostate cancer was being significantly over-treated.

The paper by Chamie et al. (which is freely available as a full text article) reports on analysis of data from the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked databases for 37,621 men in the general community diagnosed as having prostate cancer between 2004 and 2007 and who were followed until December 31, 2009. It must, therefore be recognized that the research team is reporting based on men diagnosed roughly 10 years in the past, and all of these were aged 65 or older (for reasons indicated below). A news report is also available on the web site of the UCLA Jonsson Comprehenive Cancer Center

It is worth noting, immediately, that the SEER–Medicare linked database included a total of 45,408 men diagnosed with prostate cancer between 2004 and 2007 with follow-up of Medicare services through 2009. The authors excluded from their analysis 7,787 men for any one or more of the following reasons:

  • The diagnosis was obtained from a death certificate or autopsy.
  • This was not the patient’s first and only malignant neoplasm.
  • The prostate cancer was not pathologically confirmed.
  • The patient was enrolled in Medicare for end-stage renal disease or disability.
  • The date of diagnosis in SEER differed from that in Medicare by more than 3 months.
  • The patient was younger than 65 years at diagnosis.
  • The month of diagnosis was invalid.
  • The patient had concurrent health maintenance organization coverage and/or was not enrolled in Medicare Part A and B throughout the study period.
  • Information was lacking from 1 year prior to and 2 years after diagnosis.
  • The initial diagnostic biopsy for prostate cancer was lacking.
  • The Gleason grade, PSA level, and clinical stage were unknown.
  • Socioeconomic and co-morbidity data were unknown.

In other words, Chamie et al. made a thorough attempt to assure that they had identified an accurately diagnosed cohort of men who met certain very specific criteria.

Here are some of the core study findings:

  • The majority of the patients
    • Were aged between 65 and 74 years (22,929/37,621 or 60.9 percent)
    • Had Gleason scores of either ≤ 6 (16,482/37,621 or 43.8 percent) or 7 (14,706/37,621 or 39.1 percent)
    • Had clinical stage T1 (20,695/37,621 or 55.0 percent) or T2 (15,756/37,621 or 41.9 percent) disease
    • Had PSA levels between 4.1 and 9.9 ng/ml (21,780/37,621 or 57.9 percent)
    • Met classification characteristics for D’Amico intermediate-risk disease (19,962/37,621 or 53.1 percent)
  • The commonest forms of treatment were
    • Radiation therapy (57.9 percent) — inclusive of all types of radiation therapy
    • Radical prostatectomy (19.1 percent)
    • Androgen deprivation therapy or ADT (10.8 percent)
    • Expectant management (9.6 percent) — inclusive of both watchful waiting and active surveillance
    • Cryotherapy (2.6 percent)
  • Radiation therapy was the most common treatment type regardless of stage, PSA level, Gleason grade, or D’Amico tumor risk.
  • Application of radical prostatectomy was significantly influenced by PSA level (from 24 percent among men with PSA levels of ≤ 4.0 ng/ml to 9 percent among men with PSA level of ≥ 20 ng/ml.
  • Application of expectant management was guided by clinical stage, Gleason grade, and D’Amico tumor risk.
  • Application of ADT was significantly influenced by clinical stage, PSA level, Gleason grade, and D’Amico tumor risk.

The most interesting of the findings from the study, however, appear to be the following:

  • Only a small proportion of variation of treatment type could be attributed to tumor characteristic, region, and year.
  • Variation in the decision to pursue radical prostatectomy was significantly affected by patient demographics (40 percent), referral to other specialists (24 percent), and unexplained surgeon factors (23 percent).
  • Variation in the decision to pursue radiotherapy was significantly affected by referral to other specialists (44 percent), as well as unexplained surgeon factors (20 percent) and patient factors (30 percent).
  • Variation in the decision to pursue expectant management was significantly affected by unexplained patient factors (58 percent) with less variation attributed to other consultants (14 percent), unexplained surgeon factors (12 percent), and patient demographics (12 percent).

Chamie et al. conclude that:

There remains an increased use of treatments in men diagnosed as having prostate cancer and underuse of active surveillance in men with low-risk disease. There is an increased use of radiotherapy among all risk groups and in particular patients with indolent disease with limited correlation according to tumor biological characteristics and patient health.

What seems very evident to The “New” Prostate Cancer InfoLink from this study is that, 10 years ago, there was little real consensus across the prostate cancer-treating community about (a) the “best” ways to manage indolent prostate cancer or (b) the validity of expectant management as a way to care for men with low-risk/indolent disease. It has to be remembered that, at the time the men in this study were being diagnosed and treated, there were no guidelines from the NCCN stating categorically that all men with low- or very low-risk prostate cancer and a life expectancy of 10 years or less should be managed on active surveillance as a first choice. It will be interesting to see, in about 2021 or 2022, whether the issuance of the NCCN guidelines on this topic made a significant difference to physician recommendations in the “real world” of community practice.

One Response

  1. Though a fairly short 3-year time span, the overall long-term trend to earlier detection should have resulted in an increase in the percentage of patients eligible for expectant management (EM) during the course of that 3-year pool. A year by year stratification of the pool would logically show an increase in EM, particularly as EM gained backing as a proper tool. I fear the year by year would not show those effects, as I fear your 2021/2022 groups will be less dramatically different than they should be.

    Maybe those big nasty insurance companies will start to require approval for treatments that do not meet NCCN guidelines. The howling would be very loud; the science sound. Even the threat, without the actual denial of service, would probably have more impact than the guidelines.

    Maybe I’m just in a mood.

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