Trends in the management of localized prostate cancer: 2000 to 2010

The international trend back toward increased use of more conservative management techniques (e.g., active surveillance and watchful waiting) for men with low-risk disease is again indicated in data from the Anglian region of the National Health Service in the UK. The entire text of this paper by Greenberg et al. is available on line in the journal PLoS One.

The authors studied treatment patterns for > 10,000 men who were all diagnosed in a specific region of the UK with non-metastatic, localized prostate cancer between 2000 and 2010, with a particular focus on men who received four types of treatment:

  • Radical prostatectomy
  • External beam radiation therapy
  • Primary androgen deprivation therapy (ADT)
  • Conservative management (i.e., no immediate invasive treatment, and including any form of active surveillance or watchful waiting)

The primary findings of their study are as follows:

  • The total number of patients for whom there was sufficient evaluable data was 10,365.
    • 1,435 treated by radical prostatectomy
    • 3,320 treated by external beam radiation therapy
    • 3,590 treated by primary ADT
    • 2,020 receiving conservative management
  • During the 10-year time frame, there was
    • A 50 percent reduction in the initial use of of primary ADT
    • A significant rise in the application of conservative management techniques (from 7 to 22 percent)
    • An age-dependent rise in the use of radical prostatectomy (by about 100 percent)
    • No significant overall change in the initial use of external beam radiation therapy
  • When the authors categorized the patients by both age and risk group, they found that
    • Men ≤ 60 years with low-risk disease were more likely to be given conservative management than radical therapy (p < 0.0001).
    • Men ≤ 60 years with intermediate-risk disease showed little change in their patterns of treatment over time.
    • Men ≤ 60 years with high-risk disease were more likely to be treated with radical prostatectomy than external beam radiation therapy (p = 0.009).
    • Men between 60 and 69 years with low- and intermediate-risk disease were more likely to be given conservative management towards the end of the decade (p < 0.0001 and p < 0.028 respectively).
    • Men between 60 and 69 years of age with high-risk disease were more likely to receive radical prostatectomy by the end of the decade (p < 0.0001)
    • Men ≥ 70 years with low-risk disease were nearly twice as likely to be given conservative management over the entire decade, while rates of all other treatments fell (p < 0.0001).
    • Men ≥ 70 years with intermediate- and high-risk cancers were more likely to receive radical prostatectomy, but represented only 4 percent of all men treated.
    • There were no major shifts in treatment trends for men ≥ 80 years, and  primary ADT remained the most common treatment for this demographic.

Greenberg et al. conclude that their study had “… identified significant shifts in non-metastatic prostate cancer management over the last decade.” In particular, they emphasized that:

  • Conservative management had become the primary management strategy  for men with low-risk disease.
  • High-risk disease had become increasingly managed by radical treatments.
  • Treatment of high-risk, younger men with radical prostatectomy was supported by evidence of lower levels of cancer-specific mortality (but that this benefit wass not evident in older men).

These data appears to be consistent with data from several other studies, but it also appears that the speed of re-uptake of conservative management is more common in other nations than it has been in America, where there are clear, early financial benefits to surgeons and radiation oncologists in private practice from implementation of invasive forms of treatment.

In general, based on the data that are now available, it makes a lot of sense to see

  • Men with low-risk disease being treated conservatively at first
  • Younger men with intermediate- and high-risk disease being treated more aggressively early on (in the hope of a cure or at least a long-term remissi0n)

However, The “New” Prostate Cancer InfoLink would emphasize the importance of individualization of care to each specific patient and his situation. Prostate cancer and its management is absolutely not suited to “one size fits all” solutions. Regardless of the patient’s age, and the aggressiveness of his cancer, there are careful decisions that need to be made about management by each individual patient with the input and assistance of his physician(s).

2 Responses

  1. It would have been interesting to also have learned failure statistics of these men who received surgical removal since this treatment was most administered. Apparently brachytherapy was not available to these men since it was not mentioned. Interesting the little administration of external beam radiation (urologist encouragement to radical prostatectomy?)

  2. Dear Chuck:

    This study was only designed to examine the way treatments had changes in prevalance over the 10-year period, not the patients’ outcomes.

    Also, I am somewhat puzzled by your comment about “little administration of external beam radiation.” Some 3,320 of the patients in this study received external beam radiation as their first-line therapy. That’s 32% of the total number of evaluable patients, and significantly higher than the numbers of patients treated surgically.

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