The use of advanced treatment technologies for prostate cancer, such as intensity-modulated radiotherapy (IMRT) and robotic prostatectomy, has increased among men with low-risk disease—despite the fact that this population is unlikely to benefit from these treatments, according to a study published in JAMA.
Each year in the United States, more than 240,000 men are diagnosed with prostate cancer and more than 27,000 die of the disease. Prostate cancer is typically a disease of aging. It may persist undetected for many years without causing symptoms. In fact, most men die with prostate cancer not from prostate cancer. Approximately 20% of men will develop prostate cancer during their lifetime, yet only 3% will actually die of the disease.
The treatment of early-stage prostate cancer is controversial because thus far there is no clear proof that aggressive treatment prolongs survival compared with deferred treatment. Furthermore, treatment can cause lasting side effects, such as impotence and incontinence. Some men opt for a more conservative approach, called active surveillance or watchful waiting—which defers treatment until symptoms appear and/or there is evidence of progression. This approach can help some men avoid unnecessary treatment and potentially long-lasting side effects.
As prostate cancer treatment has advanced, it appears more men are utilizing the advanced technologies. Researchers conducted a retrospective cohort study to evaluate the use of advanced treatment technologies (IMRT and robotic prostatectomy) compared with the use of prior standards of treatment (traditional external beam radiation treatment and open radical prostatectomy) and observation among men with a low risk of dying from the disease.
The researchers used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify a cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (23,633 men), EBRT (3,926), robotic prostatectomy (5,881), open radical prostatectomy (6,123), or observation (16,384). Follow-up data were available through December 2010. Low-risk disease was defined as clinical stage ? T2a, biopsy Gleason score ? 6, and prostate-specific antigen level ? 10 ng/mL. High risk of non-cancer mortality was defined as the predicted probability of death within 10 years in the absence of a cancer diagnosis.
The results indicted that the use of advanced treatment technologies is on the rise among men with low-risk disease—increasing from 32 percent in 2004 to 44 percent in 2009. What’s more, men with a high risk of non-cancer mortality are increasingly using these advanced treatments (from 36% in 2004 to 57% in 2009), as are men with both low-risk disease and a high risk of non-cancer mortality (from 25% in 2004 to 34% in 2009).
Among all patients diagnosed with prostate cancer in SEER, the use of advanced treatment technologies for men unlikely to die of prostate cancer increased from 13 percent in 2004 to 24 percent in 2009, a relative increase of 85%. During the same time period, the use of prior standard treatments in this group of men decreased from 11 percent to 3 percent. It appears that these advanced technologies are being used in place of the previous treatments—i.e. IMRT is being substituted for EBRT and robotic prostatectomy is being substituted for open radical prostatectomy regardless of whether they pose an advantage. However, low-risk men are unlikely to benefit from these treatments.
The researchers concluded that among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of non-cancer mortality, or both, the use of advanced treatment technologies has increased. They suggest that continued efforts to differentiate between low-risk and high-risk disease might prevent such overtreatment in the future.
Jacobs BL, Zhang Y, Schroeck FR, et al. Use of advanced treatment technologies among men at low risk of dying from prostate cancer. JAMA. 2013; 309(24): 2587-2595.