AIM: Prostate cancer therapy trends moving in wrong direction

Men with localized prostate cancer may not be receiving curative therapy (CTx) in accordance with potential clinical benefit, as patients with a low likelihood to benefit have received increasingly aggressive treatment in recent years while patients in groups that are likely to benefit from CTx have not seen comparable increases in treatment, according to a research letter published in the Feb. 27 issue of Archives of Internal Medicine.

Life expectancy and tumor characteristics are clinical factors affecting the likelihood that a prostate cancer patient will benefit from treatments such as radiation therapy or prostatectomy, according to Ann C. Raldow, MD, of Yale University School of Medicine in New Haven, Conn., and colleagues.

Practice guidelines from the National Comprehensive Cancer Network recommend active surveillance over CTx in patients with low-risk tumors and life expectancies of less than 10 years, while more aggressive treatment is recommended for patients with intermediate-risk tumors and life expectancies longer than 10 years.

To determine whether patterns of care reflected these recommendations, the researchers accessed the Surveillance, Epidemiology, and End Results (SEER) Medicare database for men diagnosed with prostate cancer between 1998 and 2007. A total of 39,270 patients with a median age of 74 years old were included in the study sample, and 43.2 percent had moderate-risk tumors.

Results showed that 64.3 percent of patients in the overall study sample received CTx. There was a strong association between life expectancy and receipt of CTx as patients with short, intermediate and long life expectancy received CTx at rates of 39.1, 62.7 and 75.1 percent, respectively.

Despite the overall association between long life expectancy and receipt of CTx, which is in line with recommendations, the trends over the study period were moving in the wrong direction as patients who stand to benefit the least saw the greatest increase in CTx rates. Among men with moderate-risk prostate cancer, there was an increase from 38 percent to 52.1 percent in the CTx rates of the short life expectancy group. CTx use decreased slightly from 80.7 to 80 percent among men with a long life expectancy. In men with low-risk tumors, CTx use went down for men in the long life expectancy category and increased for men with short to intermediate life expectancies.

Overall CTx use increased from 61.2 percent to 67.6 percent over the study period.

“Given widespread concerns about the rate of increase in Medicare expenditures, it is notable that the most substantial increase in treatment in our sample was noted among the patients who were least likely to benefit,” wrote the authors.

Raldow and colleagues suggested possible explanations for the trends might lie in the structure of financial incentives, the emergence of new therapies and changes in patient preferences.

“The use of cancer therapies should be informed by clinical evidence and guided by patient preferences," the authors concluded. "Future work should explore how better to incorporate both cancer characteristics and patient [life expectancy] into decision making.”