The management of patients with localized prostate cancer has improved to meet clinical guidelines, according to a new study.
The management of patients with localized prostate cancer has improved to meet clinical guidelines, according to a study published in JAMA.
Both overtreatment of low-risk disease and undertreatment of higher-risk disease have been of concern at community practices in the United States. But, the new prospective survey shows encouraging trends. Between 2010 and 2013 there was an increase in the use of active surveillance for men with low-risk prostate cancer, with a rate of 40% compared with 10% seen in the prior 20 years. Concurrently, the use of androgen deprivation monotherapy has decreased to 24% for high-risk prostate cancer cases and 3.8% for intermediate-risk cases, suggesting that these tumors are being more aggressively treated, as recommended by guidelines. Previously, treatment with androgen deprivation for intermediate-risk and high-risk tumors had steadily increased starting in 1990.
Study authors Matthew R. Cooperberg, MD, MPH, and Peter R. Carroll, MD, MPH, of the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco, analyzed data from the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) national registry to understand the current community-based patterns of care for localized prostate cancer. CaPSURE includes prostate cancer patients diagnosed since 1995 at 45 urology practices across 28 states. All but three of the centers included are community-based practices. All 10,472 men included in CaPSURE were classified as stage cT3aN0M0 or lower and received radiation, androgen deprivation monotherapy, active surveillance/watchful waiting, or a prostatectomy. The average age of the patients was 66 years.
According to the study authors, the data are particularly meaningful because they are from the community setting. The effectiveness and safety of active surveillance had previously been established at academic centers, while community centers have been slower to adopt this type of management for prostate cancer patients.
Surveillance for low-risk disease was low-between 7% and 14%-from 1990 through 2009, and then increased sharply to 40% between 2010 and 2013.
Among men age 75 years and older, 54% underwent surveillance between 1990 and 1994; the rate decreased to 22% between 2000 and 2004 and then increased to 76% between 2010 and 2013. Surgery increased among this same age group to 9.5% for men with low-risk disease and 15% for men with intermediate-risk disease. Surgery rates stayed the same among high-risk prostate cancer patients. About 67% of patients in this group received androgen deprivation therapy.
“The magnitude and speed of the changes suggest a genuine change in the management of patients with prostate cancer in the United States, which could accelerate as more clinicians begin to participate in registry efforts,” wrote Cooperberg and Carroll. “Given that overtreatment of low-risk disease is a major driver of arguments against prostate cancer screening efforts, these observations may help inform a renewed discussion regarding early detection policy in the United States.”