Advanced Treatment Options for Men with Low-Risk Prostate Cancer

Results of a retrospective cohort study [JAMA. 2013;309(24):2587-2595] show that between 2004 and 2009, the use of advanced treatment technologies for men with prostate cancer with low-risk disease, those at high risk of noncancer mortality, or men with both low-risk disease and at high risk of noncancer mortality, increased.

To assess the use of advanced treatment technologies compared with traditional treatments and observation among men with a low risk of dying from prostate cancer, investigators used Surveillance, Epidemiology and End Results (SEER)-Medicare data to retrospectively identify a cohort of men diagnosed with prostate cancer between 2004 and 2009. Men with a low risk of dying from prostate cancer included those with low-risk disease (clinical stage <T2a, biopsy Gleason score <6, and prostate-specific antigen level <10 ng/mL), a high risk of noncancer mortality (based on the predicted probability of death within 10 years with no cancer diagnosis), or both.

Men ≥66 years of age who were fee-for-service beneficiaries eligible for Medicare Parts A and B from 12 months prior to and 12 months after diagnosis were included in the study. Men aged ≤65 were excluded.

The data showed that among the men treated with advanced treatment technologies, 23,633 were treated with intensity-modulated radiotherapy (IMRT) and 5881 were treated by robotic prostatectomy. Among the men treated with traditional treatments, 3926 were treated with external beam radiation treatment (EBRT) and 6123 were treated by open radical prostatectomy. In addition, 16,384 underwent observation.

Based on these data, the study showed that the use of advanced technologies significantly increased from 32% to 44% among men with low-risk disease (P<.001) and from 36% to 57% among men with a high risk of noncancer mortality (P<.001). For men with low-risk disease and a high risk of noncancer mortality, the use of advanced technologies significantly increased from 25% to 34% (P<.001).

Among the advanced technologies, IMRT accounted for the greatest use with an increase from 27% to 33% among men with low-risk disease, from 35% to 52% in men with a high risk of noncancer mortality, and from 24% to 32% in men with both low-risk disease and a high risk of noncancer mortality.

Robotic prostatectomy was used less frequently than IMRT, but also increased from 5% to 11% among men with low-risk disease, 2% to 5% in those at high risk of noncancer mortality, and 1% to 3% for both.

Overall, the study found that the use of IMRT and robotic prostatectomy increased from 129.2 per 1000 patients to 244.2 per 1000 patients between 2004 and 2009.

During this same period, use of prior standard treatments significantly decreased from 11% to 3% (P<.001). Use of EBRT and open radical prostatectomy decreased from 106.9 per 1000 patients to 27.2 per 1000 patients.

According to the investigators, important implications of these findings include the fact that both advanced technologies are more expensive than prior standard treatments as well as the use of these advanced technologies during a period of increased awareness of the indolent nature of prostate cancer and the discussion of limiting treatment in patients with a low risk of dying of prostate cancer.

The authors concluded that reducing the use of advanced treatment technologies in this patient population may come from continued efforts to differentiate between indolent and aggressive cancers to improve prediction of life expectancy.

They also suggested the need for policy changes to help curtail the excessive use of these advanced technologies for men who are least likely to benefit from them. For example, they cited the use of a value-based insurance design that discourages the use of services when the benefits do not justify the cost.