Use of advanced treatment technologies among men at low risk of dying from prostate cancer

Abstract

Importance: The use of advanced treatment technologies (ie, intensity-modulated radiotherapy [IMRT] and robotic prostatectomy) for prostate cancer is increasing. The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain.

Objective: To assess the use of advanced treatment technologies, compared with prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer.

Design, setting, and patients: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified a retrospective cohort of men diagnosed with prostate cancer between 2004 and 2009 who underwent IMRT (n = 23,633), EBRT (n = 3926), robotic prostatectomy (n = 5881), open radical prostatectomy (n = 6123), or observation (n = 16,384). Follow-up data were available through December 31, 2010.

Main outcomes and measures: The use of advanced treatment technologies among men unlikely to die from prostate cancer, as assessed by low-risk disease (clinical stage ≤T2a, biopsy Gleason score ≤6, and prostate-specific antigen level ≤10 ng/mL), high risk of noncancer mortality (based on the predicted probability of death within 10 years in the absence of a cancer diagnosis), or both.

Results: In our cohort, the use of advanced treatment technologies increased from 32% (95% CI, 30%-33%) to 44% (95% CI, 43%-46%) among men with low-risk disease (P < .001) and from 36% (95% CI, 35%-38%) to 57% (95% CI, 55%-59%) among men with high risk of noncancer mortality (P < .001). The use of these advanced treatment technologies among men with both low-risk disease and high risk of noncancer mortality increased from 25% (95% CI, 23%-28%) to 34% (95% CI, 31%-37%) (P < .001). Among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13% (95% CI, 12%-14%), or 129.2 per 1000 patients diagnosed with prostate cancer, to 24% (95% CI, 24%-25%), or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001).

Conclusion and relevance: Among men diagnosed with prostate cancer between 2004 and 2009 who had low-risk disease, high risk of noncancer mortality, or both, the use of advanced treatment technologies has increased.

Figure 1

Treatment of Prostate Cancer Among Men Who Are the Least Likely to Benefit The percentage of treatment was adjusted for age, race, socioeconomic class, comorbidity, tumor grade, year of diagnosis, and Surveillance, Epidemiology, and End Results region. Use of advanced treatment technologies significantly increased among prostate cancer patients with low-risk disease, high risk of noncancer mortality, and both low-risk disease and high risk of noncancer mortality (P<.001 for trend). Conversely, there was a decreased use of prior standards among these patients (P<.001 for trend), making the overall use of treatment relatively stable over time. Error bars indicate 95% CIs; EBRT, traditional external beam radiation treatment; IMRT, intensity-modulated radiotherapy.

Figure 2

Use of Advanced Treatment Technologies Among Prostate Cancer Patients Who Are the Least Likely to Benefit The percentage of treatment was adjusted for age, race, socioeconomic class, comorbidity, tumor grade, year of diagnosis, and Surveillance, Epidemiology, and End Results region. Use of intensity-modulated radiotherapy (IMRT) and robotic prostatectomy both increased among men who stand the least to gain in terms of survival (both P<.001 for trend). The majority of these patients were treated with IMRT. Error bars indicate 95% CI.

Figure 3

Estimating the Use of Prostate Cancer Treatments for Men Least Likely to Benefit Among Medicare beneficiaries diagnosed with prostate cancer, the use of advanced treatment technologies increased from 13% (95% CI, 12%–14%) in 2004 to 24% (95% CI, 24%–25%) in 2009 for men unlikely to die of prostate cancer (P <.001, Pearson χ² test). At the same time, the use of prior standard treatments for these patients decreased 8% (P <.001, Pearson χ² test).

Figure 4

Estimating the Use of Prostate Cancer Treatments for Men Most Likely to Benefit Among Medicare beneficiaries diagnosed with prostate cancer, the use of advanced treatment technologies for men most likely to benefit (ie, those with high-risk disease or a low risk of noncancer mortality) increased 11%, while the use of prior standards decreased 10% over the study period (both P <.001, Pearson χ² test).