Locally advanced prostate cancer: a population-based study of treatment patterns

摘要

OBJECTIVE class="unordered" style="list-style-type:disc" id="L1">To identify treatment patterns and predictors of receiving multimodality therapy in patients with locally advanced prostate cancer (LAPC).PATIENTS AND METHODS class="unordered" style="list-style-type:disc" id="L2">The cohort comprised patients ≥ 66 years with clinical stage T3 or T4 non-metastatic prostate cancer diagnosed between 1998 and 2005 identified from the Surveillance, Epidemiology and End Results (SEER) cancer registry records linked with Medicare claims.Treatments were classified as radical prostatectomy (RP), radiation therapy (RT) and androgen deprivation therapy (ADT) received within 6 and 24 months of diagnosis.We assessed trends over time and used multivariable logistic regression to identify predictors of multimodality treatment.RESULTS class="unordered" style="list-style-type:disc" id="L3">Within the first 6 months of diagnosis, 1060 of 3095 patients (34%) were treated with a combination of RT and ADT, 1486 (48%) received monotherapy (RT alone, ADT alone or RP alone), and 461 (15%) received no active treatment.The proportion of patients who received RP increased, exceeding 10% in 2005 .Use of combined RT and ADT and use of ADT alone fluctuated throughout the study period.In all 6% of patients received RT alone in 2005.Multimodality therapy was less common in patients who were older, African American, unmarried, who lived in the south, and who had co-morbidities or stage T4 disease.CONCLUSIONS class="unordered" style="list-style-type:disc" id="L4">Treatment of LAPC varies widely, and treatment patterns shifted during the study period.The slightly increased use of multimodality therapy since 2003 is encouraging, but further work is needed to increase combination therapy in appropriate patients and to define the role of RP. class="kwd-title">Keywords: prostate cancer, locally advanced, treatment, SEER, practice patterns class="head no_bottom_margin" id="S5title">INTRODUCTIONMore than 200,000 men will be diagnosed with prostate cancer in the United States this year and up to 10% will have locally advanced disease (clinical stage T3 or T4) at presentation [,]. Numerous modalities, alone and in combination, have been advocated for treating these patients, but consensus guidelines are lacking. Mounting evidence supports the use of a multimodality approach to treat locally advanced prostate cancer (LAPC), including some combination of radiation therapy (RT) with androgen deprivation therapy (ADT) or radical prostatectomy (RP) with adjuvant RT. Indeed, multiple randomized controlled trials have demonstrated a survival advantage to combined RT and ADT compared with either modality alone [–]. Furthermore, adjuvant RT or ADT after RP in select patients with pathologically advanced prostate cancer confers a significant survival advantage [,–].The role of radical surgery for these patients has not been investigated systemically. Traditionally RP has not been routinely used in LAPC except in patients with low-volume, clinically staged T3 prostate cancer. Recent evidence suggests that patients with higher-risk prostate cancer treated initially with RP could have lower risks of metastatic progression and prostate cancer-specific death than those treated with RT initially []. Attempts to reduce the likelihood of biochemical recurrence after RP by using up to 8 months of neoadjuvant ADT have been unsuccessful [–]. The management of other clinically localized, high-risk solid tumours, such as breast and colon cancer, frequently combines surgery with other treatment modalities [,]. Such an approach has had limited success in prostate cancer. However, with refinements in RP technique and a reduced risk of perioperative complication rates, the role of surgery in combination with RT, chemotherapy or ADT for patients with LAPC is evolving.On a population level, surprisingly little is known about LAPC treatment patterns and the proportion of patients receiving various treatment modalities. There is a poor understanding of which factors influence the type of treatment these patients receive and why some receive monotherapy while others are treated with multimodal strategies. Our objective was to characterize treatment patterns for clinically staged T3 and T4 prostate cancer in a population-based patient cohort and to identify predictors of multimodality therapy.