Localized PCa Tx: An evolving landscape

August 25, 2014

A recent study confirms that treatment choices for localized prostate cancer are not stagnant but continue to evolve, writes Leonard G. Gomella, MD.

Leonard G. Gomella, MDDr. Gomella,

In a study reported in the September 2014 issue of Urology Times, colleagues from the Moffitt Cancer Center studied 2004-2010 Surveillance, Epidemiology, and End Results (SEER) data for changes in the treatment of localized prostate cancer. They noted an increase in surgery, a decrease in brachytherapy, and the expected increase in “no treatment,” presumed to mostly represent active surveillance. Patients less likely to receive treatment had low-risk disease and were >65 years of age, expected results with the growth of active surveillance.

What is not clear is why men who were African-American, single, or resided in a county with a low educational level were less likely to receive any form of active treatment. This report deserves further analysis to dissect out active surveillance from those who needed active intervention but received none, a significant concern.

The decline in brachytherapy is relatively easy to explain based on the growth of intensity-modulated radiation therapy units, evolving reimbursement models, and the relative increase in surgery. Is this increase in surgery a bad thing? Not if you believe data such as the recent observational study of 35,000 Swedish men. With 15-year follow-up, in most men with non-metastatic prostate cancer, surgery leads to better survival than radiotherapy (BMJ 2014; 348:g1502). While this SEER study covered the early ramp-up period of robot-assisted radical prostatectomy, it is likely that the competitive adoption of this technology, coupled with enhanced marketing efforts by the manufacturer and providers, reinvigorated interest in the surgical approach to prostate cancer.

Behind this observational data it is important to recognize the factors that influence these treatment decisions. These data also reflect the influence of the counseling physicians who have a well-documented and significant impact on the choice of upfront therapy.

Although this study is limited, examining data only through 2010, it confirms that treatment choices for localized prostate cancer are not stagnant but continue to evolve. Hopefully, these changes are for the better, with some trends easily understood and others needing a closer look.UT

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