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Surgery up, brachytherapy down for localized PCa


Use of surgery has increased steadily among all men with clinically localized prostate cancer, and in those with low-risk disease, brachytherapy utilization has declined.

Chicago-Use of surgery has increased steadily among all men with clinically localized prostate cancer, and in those with low-risk disease, brachytherapy utilization has declined.

Those are among the findings of a population-based analysis of management for localized prostate cancer, which identified some particularly interesting trends in men with low-risk disease.

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The study, which was presented at the American Society of Clinical Oncology annual meeting in Chicago, extracted information from the Surveillance, Epidemiology, and End Results database for the years 2004 to 2010. It identified 216,785 men with clinically localized prostate cancer for whom primary treatment could be determined. Based on National Comprehensive Cancer Network criteria, 29% of men were at low risk for recurrence, 49% were in the intermediate-risk category, and 22% had a high risk for prostate cancer recurrence.

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Researchers observed a steady increase in surgery utilization from 2004 to 2010 across all risk categories. In 2004, surgery accounted for 37.7% of primary treatment, and it rose by 1.38% annually to account for 45.3% of primary treatment in 2010.

Looking specifically at the group with low-risk disease, the study showed a steady decrease in brachytherapy utilization and continuous growth in the proportion of men receiving no treatment.

Results of a multivariate analysis showed men were more likely to receive no treatment if they were diagnosed in 2010, in the low recurrence risk group, single, African-American, >65 years of age, or residing in a county with a low education level (high school graduate rate <75%).

“Analyses of this type are very helpful for providing insight about how emerging information pertaining to patient care and developments in treatment are impacting medical practice throughout the nation,” said co-author Julio Pow-Sang, MD, chair of genitourinary oncology, chief of surgery services, and director of the robotics program at H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL.

“The documentation of increasing utilization of no treatment among men with low-risk disease confirms data from other studies and is not surprising given the accumulation of reports in the past decade supporting this option. However, it is a little more difficult to explain why African-American men and those residing in areas with a low education level were more likely to receive no treatment.”


Factors behind lower seed use

First author Kamran Ahmed, MD, radiation oncology resident at the H. Lee Moffitt Cancer Center, postulated there may be a few factors explaining the decrease in brachytherapy utilization over the study period.

“Increasing utilization of intensity-modulated radiation therapy may play a role as well as shifts in patterns of reimbursement. These findings may also point to a need for better brachytherapy training during residency in order for radiation oncologists to feel comfortable performing these procedures when out in practice,” he told Urology Times.

Data for the low recurrence risk group showed that overall, 27.7% received no treatment, 25.9% received external beam radiation therapy (EBRT), 24.5% received brachytherapy, 16.7% underwent surgery, and 4.9% had EBRT + brachytherapy. The percentage of low-risk patients undergoing no treatment increased by 2.57% annually. Utilization of brachytherapy in the low-risk group decreased by 2.29% annually and by 14.3% during the study period.

Dr. Pow-Sang postulated that the general increase in surgery utilization might be related to increasing access to robotic technology and further fueled by merging of smaller urology groups into larger practices that include a robotically trained member.

“Robotic technology was introduced to the U.S. in 2002, was fairly rapidly adopted, and had high penetration by 2010. With the advent of robotic technology, small urology groups began to merge into larger groups that specifically hired robotically trained surgeons so that the group could offer robotic procedures. In this setting, there may be increasing internal referrals for robotic prostatectomy,” Dr. Pow-Sang said.UT

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