High-Tech Treatments Increasingly Used in Low-Risk Prostate Cancer

Roxanne Nelson

June 25, 2013

The use of advanced treatment technologies has increased among prostate cancer patients who are unlikely to benefit, according to a new study.

Therapies such as intensity-modulated radiotherapy (IMRT) and robotic prostatectomy are being increasingly utilized in men with low-risk disease and/or a low risk of dying from prostate cancer. This is despite the growing awareness of the indolent nature of some prostate cancers, the study authors note, as well as "growing dialogue" about overtreatment.

The study appears in the June 26 issue of JAMA.

The researchers found that the use of advanced treatment technologies increased from 32% in 2004 to 44% in 2009 in men with low-risk disease, from 36% in 2004 to 57% in 2009 among those with a low risk for prostate cancer mortality, and from 25% in 2004 to 34% in 2009 in patients with both low-risk disease and a low risk for cancer mortality.

Because of its retrospective nature, the study does not answer a number of questions, commented senior author Brent K. Hollenbeck, MD, an associate professor of urology at the University of Michigan, Ann Arbor. "Certainly there are both physician preferences and patient preferences for treatment, and the answer lies at the intersection of the patient-physician interaction," he told Medscape Medical News.

There are a reasonable proportion of men with prostate cancer with low-risk disease, a low risk for cancer mortality, or both who are still being treated. "And primarily with IMRT, if you look at our data," he said. "What we've tried to do is unlink diagnosis from treatment, but if anything, this study highlights that has been difficult to do."

He pointed out that there is a gray area of whether or not to treat. "In American culture, there is a tendency to do something, and to some extent, that may be what is happening here," Dr. Hollenbeck added.

The authors note that there may be several potential explanations for their results, one being the uncertainty about the natural history of prostate cancer. Even in low-risk situations, patients or physicians may be reluctant to simply observe when treatment offers a high possibility of cure. Another reason is that a perceived improvement in outcomes with advanced technologies, compared with prior alternatives, may make these modalities seem more palatable. Finally, financial incentives, such as ownership opportunities, growing market share, and fee-for-service reimbursement, can be quite powerful.

Interesting but Not Surprising

Commenting on the study, David F. Penson, MD, MPH, notes that although the results are interesting, they are not surprising. "For the most part, they reflect what happens when new technologies are diffused into practice, as opposed to inappropriate utilization," said Dr. Penson, Hamilton and Howd Chair in Urologic Oncology at Vanderbilt University Medical Center, Nashville, Tennessee.

He feels that the use of advanced treatment technologies in men with low-risk disease is unlikely to be related to financial incentives. "The reason I say that is that urologists don't make more money for doing robotic prostatectomies than they do for open procedures, yet we see an increase in the use of robotic surgery," Dr. Penson pointed out. "It must be something else. I believe patients want the most advanced technology, which leads them to request IMRT or robotic surgery over open surgery or older EBRT [external beam radiation therapy] techniques."

"While there are always financial incentives in medicine that impact care, this article doesn't reflect that," he added.

Better ways are needed to identify indolent disease, he said, and "this study shows what many other authors have shown — that we overtreat prostate cancer in the United States. This is driven primarily by clinical uncertainty about how dangerous the cancer and a societal belief that cancer has to be treated no matter what."

"We need to change how we approach this disease, and that's going to require patients to rethink things as much as doctors," Dr. Penson said.

Already Down the Path

Another expert agrees that the perception of cancer can drive treatment in this population. "Once you say cancer, it can be hard to have that rational conversation with the patient," said Bruce Roth, MD, professor of medicine at Washington University School of Medicine, St. Louis, Missouri.

However, he also points out that the period covered in this study was before new recommendations on prostate-specific antigen (PSA) screening were issued. "Screening rates are down, so there is a lead time, and we are not going to see a change for a number of years," Dr. Roth said in an interview. "Also, when we look at this type of data, we are almost preselecting people who have chosen to do something. They are already down that path. They have decided to get a PSA, they have decided to get a biopsy, and it's a lot harder to stop the train once you have that diagnosis."

Dr. Roth explained that he has had this conversation with patients and that "it is much, much more difficult to talk a patient with diagnosed cancer into surveillance than to discuss whether PSA is the right choice for them."

He also pointed out that the article gives a sense that physicians are driving the process, but he believes that patients are primarily the drivers. "There is clearly a problem with direct-to-consumer marketing, and some of it may be from the technology companies, and some is from hospitals," he said. "It's not the radiation oncologists that are putting up the billboards about the new proton center."

"Not one refers themselves to a tertiary care center to get the old technology," he continued. "If they saw a billboard that you have a proton center, they don't want external beam radiation treatment. They came there for a reason. It kind of feeds on itself in a vicious cycle — patients demand more technology, and there are those willing to provide it."

Essentially, there are really 2 issues at stake, he noted. One is with regard to the patient who actually needs to be treated and what type of therapy they should receive, and the other, which is a whole separate question, is deciding whether treatment will in fact benefit the patient.

But even if a patient is at low risk, it may not be enough to tell them they have a 25% chance of dying of prostate cancer, he said. "What they want to know is if they are going to die and if they should have therapy. And we don't have anything more discriminatory yet."

Genetic profiling tests will help improve that predictability, but "we're not there yet," Dr. Roth explained. "Maybe in 15 years we will have a genomic signature that can say if the risk of dying is 1% or it is 90% — that will change the dynamics of decision making."

"Once you go down the path for screening and making a diagnosis, you're more than halfway there to therapy," said Dr. Roth. "That's the issue more so than the specific technology that's used."

Study Details

In this study, Dr. Hollenbeck and colleagues assessed the use of advanced treatment technologies, as compared with previous standards (ie, traditional EBRT and open radical prostatectomy) and observation, among men with a low risk of dying from prostate cancer.

They used the Surveillance, Epidemiology, and End Results (SEER)–Medicare data to identify 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). The follow-up data were available through December 31, 2010.

The use of advanced treatment technologies was evaluated among men who were unlikely to die from prostate cancer, as assessed by low-risk disease, a low risk for cancer mortality (determined on the basis of predicted probability of death within 10 years in the absence of a cancer diagnosis), or both.

In addition, the authors estimated the use of prostate cancer treatments for men least likely and most likely to benefit. They found that among all patients diagnosed in SEER, the use of advanced treatment technologies for men unlikely to die from prostate cancer increased from 13%, or 129.2 per 1000 patients diagnosed with prostate cancer, to 24%, or 244.2 per 1000 patients diagnosed with prostate cancer (P < .001).

The rates of IMRT and robotic prostatectomy use increased from 129.2 per 1000 patients in 2004 to 244.2 per 1000 patients in 2009.

During the same period, the use of prior standard treatments in this population decreased from 11% in 2004 to 3% in 2009 (P< .001). Among this group, the rates of EBRT and open radical prostatectomy use declined from 106.9 per 1000 patients diagnosed with prostate cancer in 2004 to 27.2 per 1000 patients diagnosed with prostate cancer in 2009.

For men who were most likely to benefit from therapy (ie, those with high-risk disease or a low risk for noncancer mortality), the estimated use of advanced treatment technologies increased 11%, while the use of prior standards decreased 10% during the study period (both P < .001).

Dr. Hollenbeck is an associate editor of the journal Urology; several coauthors have presented disclosures in the article.

JAMA. 2013;309:2587-2595. Full article

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