Early prostate cancer care ques­tioned

Modern Healthcare - - NEWS - By Sabriya Rice

Two new stud­ies are rais­ing con­cerns about man­age­ment of early stage prostate cancer and treat­ment.

Pa­tients un­der­go­ing surgery and ra­di­a­tion for early stage prostate cancer may not be in­formed of the full ar­ray of treat­ment op­tions, ac­cord­ing to one re­port. The other found that a widely used hor­mone ther­apy for lo­cal­ized prostate cancer did not in­crease sur­vival. Both stud­ies were re­leased last week in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion.

The first anal­y­sis looked at vari­a­tions in physi­cian man­age­ment of early stages of prostate cancer. It found that pa­tients di­ag­nosed by urol­o­gists were more likely to un­dergo a pro­ce­dure within 12 months of di­ag­no­sis than to sim­ply be ob­served, de­spite the slow-grow­ing na­ture of the cancer.

Also, those pa­tients were more likely to un­dergo a pro­ce­dure the urol­o­gist per­forms.

“The find­ings sug­gest that the di­ag­nos­ing urol­o­gist may in­flu­ence not only the de­ci­sion re­gard­ing up­front treat­ment but the type of treat­ment the pa­tient re­ceives,” said Dr. Karen Hoff­man, lead au­thor of the first study.

To ex­plore care-man­age­ment vari­a­tions among urol­o­gists and ra­di­a­tion on­col­o­gists for pa­tients with low-risk prostate cancer, Hoff­man and col­leagues from the Univer­sity of Texas M.D. An­der­son Cancer Cen­ter in Hous­ton an­a­lyzed data from the Na­tional Cancer In­sti­tute’s Sur­veil­lance, Epi­demi­ol­ogy, and End Re­sults Pro­gram, as well as Medi­care claims. Of 12,068 men di­ag­nosed with lowrisk prostate cancer by their urol­o­gist, 80% had un­der­gone treat­ment within one year of di­ag­no­sis, while only 20% were sim­ply ob­served, the study found.

Of 7,554 men who sub­se­quently met with a ra­di­a­tion on­col­o­gist fol­low­ing the urol­o­gist visit, 91.5% re­ceived treat­ment within a year and 8.5% were ob­served.

Pa­tients were more like- ly to un­dergo pro­ce­dures per­formed by the urol­o­gists, in­clud­ing prosta­te­c­tomy, cryother­apy, brachyther­apy or ex­ter­nal-beam ra­dio­ther­apy.

Men with PSA lev­els less than 10 ng/ml are con­sid­ered to be lowrisk, mean­ing the pa­tient’s cancer is not likely to grow or spread for many years and may not cause prob­lems dur­ing his life­time, ac­cord­ing to the Na­tional In­sti­tutes of Health. In many cases, ob­ser­va­tion is rec­om­mended to man­age the pa­tient’s dis­ease and avoid po­ten­tial side ef­fects of treat­ment.

“Our find­ings sug­gest ac­tive sur­veil­lance as a prostate-cancer man­age­ment strat­egy is un­der­used in older men with low- risk prostate cancer,” Hoff­man said. “The treat­ment you re­ceive may be a con­se­quence of the urol­o­gist who di­ag­noses your cancer.”

The study hy­poth­e­sized that treat­ment vari­a­tions could be due in part to fi­nan­cial in­cen­tives, or to urol­o­gists wit­ness­ing more of the ef­fects of late-stage dis­ease. But con­clu­sions about ei­ther mo­ti­va­tion could not be drawn from the anal­y­sis. The re­searchers also noted sev­eral study lim­i­ta­tions.

Whether the choice for watch­ful wait­ing was given to the pa­tient or the treat­ment was ul­ti­mately the most ap­pro­pri­ate could not be de­ter­mined by the re­search data. Also, the study an­a­lyzed pa­tient records from 2006 through 2009, and Hoff­man said treat­ment pat­terns may have shifted since that time fol­low­ing re­lease of up­dated rec­om­men­da­tions.

In 2010, the Na­tional Com­pre­hen­sive Cancer Net­work up­dated its guide­lines to rec­om­mend ac­tive sur­veil­lance, or watch­ful wait­ing, as the sole ini­tial treat­ment for men who met cer­tain low-risk cri­te­ria for prostate cancer.

A sec­ond study pub­lished last week eval­u­ated use of the widely used an­dro­gen-de­pri­va­tion ther­apy—or ADT—for early stage prostate cancer and found it did not im­prove 15-year sur­vival rates for lo­cal­ized prostate can­cers. Re­searchers from the Rut­gers Cancer In­sti­tute of New Jersey con­cluded that pri­mary ADT should be used only to pal­li­ate cur­rent symp­toms or pre­vent fu­ture ones.

There has been dis­agree­ment among physi­cians con­cern­ing the best tim­ing to use ADT in men with el­e­vated PSA lev­els. Some say early use of the hor­mone ther­apy be­fore symp­tom on­set can lead to bet­ter out­comes, while oth­ers say early use may lead to re­sis­tance to the treat­ment. The re­searchers looked at data on more than 66,000 men ages 66 and older di­ag­nosed with early stage prostate cancer be­tween 1992 and 2009. They found that 15-year sur­vival rates were sim­i­lar in ar­eas with both high and low us­age of the treat­ment.

“There is a limited role for ADT as pri­mary ther­apy,” study au­thors con­cluded, say­ing doc­tors and older pa­tients should care­fully weigh risks and costs be­fore ini­ti­at­ing treat­ment.

In an ac­com­pa­ny­ing com­men­tary, Dr. Quoc-Dien Trinh of Dana-Farber Cancer In­sti­tute and Dr. Deb­o­rah Schrag of Brigham and Women’s Hospi­tal said that “there is no com­pelling ev­i­dence for use of ADT alone in men with lo­cal­ized prostate cancer” and that use of the ther­apy re­mains “alarm­ingly high.”


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