Use of advanced treatment technologies among men at low risk of dying from prostate cancer
A partir de données des registres américains du cancer et de la base Medicare portant sur une cohorte de 55 947 patients atteints d'un cancer de la prostate diagnostiqué entre 2004 et 2009, cette étude évalue, par rapport aux traitements conventionnels (radiothérapie externe, prostatectomie radicale par voie ouverte), l'utilisation des traitements employant une technologie avancée (radiothérapie avec modulation d'intensité, prostatectomie assistée par robot) chez les patients présentant un faible risque de décès par cancer de la prostate
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. Prostate cancer is a common and expensive disease in the United States.1- 2 In part because of the untoward morbidity of traditional radiation and surgical therapies, advances in the treatment of localized disease have evolved over the last decade. Chief among these are the development of intensity-modulated radiotherapy (IMRT) and robotic prostatectomy. Although the evidence underlying these technologies is mixed,3- 4 both are generally perceived as being more targeted and less toxic than prior therapies. During a period of increasing population-based rates of prostate cancer treatment,5- 6 both of these advanced treatment technologies have disseminated rapidly. However, the rapid growth of IMRT and robotic prostatectomy may have occurred among men with a low risk of dying from prostate cancer.7- 8 Recognizing the protracted clinical course for most of these cancers, clinical guidelines recommend local treatment only for men with at least a 10-year life expectancy.9- 10 Men with low-risk cancer have a particularly favorable prognosis, with a much greater likelihood of dying from other causes even 20 years after diagnosis.11 Because many older men will die with rather than from prostate cancer, observation (with delayed intervention if needed) has been promoted by some experts,12 although the extent to which this has gained traction in the community is uncertain. Aggressive direct-to-consumer marketing and incentives associated with fee-for-service payment may promote the use of these advanced treatment technologies. For these reasons, we performed a study to better understand relationships among the use of advanced treatment technologies (ie, IMRT and robotic prostatectomy), prior standards (ie, traditional external beam radiation treatment [EBRT] and open radical prostatectomy), and observation for men with a low risk of dying from prostate cancer. Understanding patterns of new technology use in this population is particularly important given the growing concerns about overtreatment.