'Genuine Change' in US Prostate Cancer Management

Nick Mulcahy

July 07, 2015

At long last, changes are being seen in the management of prostate cancer in the United States. Disturbing practices appear to be markedly on the wane, especially in recent years, according to new research.

In the years 2010-2013, the use of active surveillance for low-risk disease "increased sharply" to 40% of all cases, say investigators. The rate had languished at only about 10% in the preceding 20 years.

At the same time, use of androgen deprivation as a monotherapy "decreased sharply," they note, down to only 3.8% of intermediate-risk and 24% of high-risk prostate cancer cases. These percentages represent drops of about one third and one half from earlier periods.

Both trends are desirable because they represent strategies to avoid overtreatment and undertreatment, respectively.

Notably, there have been financial incentives to both do too much and too little, depending on the patient's risk and reimbursement schemes.

"The magnitude and speed of the changes suggest a genuine change in the management of patients with prostate cancer in the United States," write Matthew Cooperberg, MD, MPH, and Peter Carroll, MD, MPH, of the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco (UCSF).

The magnitude and speed of the changes suggest a genuine change. Dr Matthew Cooperberg

The pair report on the management of prostate cancer from 1990-2013 in a research letter published online July 7 in JAMA.

The findings on active surveillance are important, in part because they come largely from community-based practice, say the authors.

The safety and efficacy of active surveillance have been established almost entirely in the setting of academic centers.

The UCSF duo used the national registry known as CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor), which consists of 45 urology practices in 28 states. All but three practices are community based, and the practices are both large and small in size.

All of the 10,472 men included in the study had localized disease (cT3aN0M0 or lower) and were managed with either prostatectomy, radiation, androgen deprivation monotherapy, or active surveillance/watchful waiting.

The men had either low-, intermediate-, or high-risk disease (determined on the basis of CAPRA scores).

The authors found that surveillance use for low-risk disease (CAPRA 0-2) "remained low" from 1990-2009 (ranging from 6.7% to 14.3%) but then dramatically spiked to 40.4% in 2010-2013 (P < .001 for trend).

During this time frame, the inappropriate use of androgen deprivation monotherapy dropped in men with intermediate-risk (from 9.7% in 1990 to 3.8% in 2010-2013) and high-risk disease (from 29.8% in 1990 to 50% in 2005-2009 and then back down to 24% in 2010-2013).

The authors explain that potentially curative local treatment should be used in these men at higher risk, rather than a systemic monotherapy. But, as widely reported, there were ongoing financial incentives for clinicians to prescribe ADT before Medicare reform occurred in 2005.

The news about active surveillance is not all that new.

At this year's annual meeting of the American Urological Association (AUA), Dr Cooperberg reported data from this very same CaPSURE registry, but they were sliced up differently.

In the United States from 2008-2013, the primary treatment for 38.4% of men with low-risk tumors was watchful waiting or active surveillance, he told the meeting.

"It is reassuring to see this evidence that active surveillance is finally being embraced in the United States," said Stacy Loeb, MD, from New York University, in New York City, who was not involved in this research and was asked for comment on the new article.

She also said that the CaPSURE data agree with other recent American registry studies, including one from the state of Michigan that reported that 49% of eligible men received active surveillance.

But Dr Loeb also told Medscape Medical News that "rates of active surveillance [in the United States] have historically been lower than observed in other countries."

In Sweden, for example, 2013 figures indicate that active surveillance is used to manage 78% of men with very-low-risk disease and 59% of men with low-risk disease, as reported earlier this year.

Nevertheless, the practice of active surveillance is increasing on both continents. "The era of active surveillance has arrived," declared Dr Loeb at the AUA meeting in May.

Why did the dramatic upturn in surveillance happen in 2010-2013?

One of the landmark events in this time frame occurred in 2010, when the National Comprehensive Cancer Network's practice guidelines for prostate cancer recommended, for the first time, the use of active surveillance as the sole initial treatment — not just an option — for many men with prostate cancer, as reported by Medscape Medical News.

The data in the new study are different for men aged 75 years and older.

The older men have seen, during the study period, an increase in the use of active surveillance. The rate in 2010-2013 was 76.2%. However, for this same recent period, there was also an increase in the use of surgery in this age group with low-risk cancer (to 9.5%) and with intermediate-risk cancer (to 15%).

CaPSURE is currently funded by the US Department of Defense and the University of California, San Francisco. Dr Cooperberg reports financial ties with both pharmaceutical and genetic testing companies involved in either prostate cancer treatment or evaluation.

JAMA. Published online July 7, 2015. Abstract


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