Early prostate cancer care questioned

Two new studies are raising concerns about management of early stage prostate cancer and treatment.

Patients undergoing surgery and radiation for early stage prostate cancer may not be informed of the full array of treatment options, according to one report. The other found that a widely used hormone therapy for localized prostate cancer did not increase survival. Both studies were released last week in the Journal of the American Medical Association.

The first analysis looked at variations in physician management of early stages of prostate cancer. It found that patients diagnosed by urologists were more likely to undergo a procedure within 12 months of diagnosis than to simply be observed, despite the slow-growing nature of the cancer.

Also, those patients were more likely to undergo a procedure the urologist performs.

“The findings suggest that the diagnosing urologist may influence not only the decision regarding upfront treatment but the type of treatment the patient receives,” said Dr. Karen Hoffman, lead author of the first study.

To explore care-management variations among urologists and radiation oncologists for patients with low-risk prostate cancer, Hoffman and colleagues from the University of Texas M.D. Anderson Cancer Center in Houston analyzed data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, as well as Medicare claims. Of 12,068 men diagnosed with low-risk prostate cancer by their urologist, 80% had undergone treatment within one year of diagnosis, while only 20% were simply observed, the study found.

Of 7,554 men who subsequently met with a radiation oncologist following the urologist visit, 91.5% received treatment within a year and 8.5% were observed.

Patients were more likely to undergo procedures performed by the urologists, including prostatectomy, cryotherapy, brachytherapy or external-beam radiotherapy.

Men with PSA levels less than 10 ng/ml are considered to be low-risk, meaning the patient's cancer is not likely to grow or spread for many years and may not cause problems during his lifetime, according to the National Institutes of Health. In many cases, observation is recommended to manage the patient's disease and avoid potential side effects of treatment.

“Our findings suggest active surveillance as a prostate-cancer management strategy is underused in older men with low-risk prostate cancer,” Hoffman said. “The treatment you receive may be a consequence of the urologist who diagnoses your cancer.”

The study hypothesized that treatment variations could be due in part to financial incentives, or to urologists witnessing more of the effects of late-stage disease. But conclusions about either motivation could not be drawn from the analysis. The researchers also noted several study limitations.

Whether the choice for watchful waiting was given to the patient or the treatment was ultimately the most appropriate could not be determined by the research data. Also, the study analyzed patient records from 2006 through 2009, and Hoffman said treatment patterns may have shifted since that time following release of updated recommendations.

In 2010, the National Comprehensive Cancer Network updated its guidelines to recommend active surveillance, or watchful waiting, as the sole initial treatment for men who met certain low-risk criteria for prostate cancer.

A second study published last week evaluated use of the widely used androgen-deprivation therapy—or ADT—for early stage prostate cancer and found it did not improve 15-year survival rates for localized prostate cancers. Researchers from the Rutgers Cancer Institute of New Jersey concluded that primary ADT should be used only to palliate current symptoms or prevent future ones.

There has been disagreement among physicians concerning the best timing to use ADT in men with elevated PSA levels. Some say early use of the hormone therapy before symptom onset can lead to better outcomes, while others say early use may lead to resistance to the treatment. The researchers looked at data on more than 66,000 men ages 66 and older diagnosed with early stage prostate cancer between 1992 and 2009. They found that 15-year survival rates were similar in areas with both high and low usage of the treatment.

“There is a limited role for ADT as primary therapy,” study authors concluded, saying doctors and older patients should carefully weigh risks and costs before initiating treatment.

In an accompanying commentary, Dr. Quoc-Dien Trinh of Dana-Farber Cancer Institute and Dr. Deborah Schrag of Brigham and Women's Hospital said that “there is no compelling evidence for use of ADT alone in men with localized prostate cancer” and that use of the therapy remains “alarmingly high.”

Follow Sabriya Rice on Twitter: @MHsrice