Prostate cancer patterns of care: less but more

By Michael Woodhead

12 Sep 2019

Fewer Australian men are receiving treatment for prostate cancer compared to a decade ago and there has been a major shift away from radiotherapy to surgical prostatectomy, a new national study shows.

The patterns of care in prostate cancer have changed substantially in recent years to reflect concerns about overtreatment of indolent cancers, according to the analysis done by a group of urologists from Queensland and NSW.

Their review of Medicare claims data from 2002 to 2016 found that treatment rates for prostate cancer had declined in recent years, but with much greater decreases seen for brachytherapy than for radical prostatectomy. Another notable trend was an increase in prostate cancer treatment rates for older men, according to the findings published in BJU International.

After increasing to a peak around 2009, rates of radical prostatectomy declined by 15% and low-dose-rate (LDR) brachytherapy declined by 58%, while the use of external beam radiotherapy  remained steady.

But the patterns of care varied according to age, with the treatment decrease among younger men likely reflecting recent guideline recommendations against prostate cancer testing and for active surveillance of men diagnosed with indolent disease, the study authors said.

In older men, treatment rates increased and there was a marked shift to the use of surgery, likely reflecting recommendations based on increased life expectancy. Treatment rates increased in the age group 75–84 years, with the rate of radical prostatectomy increasing by 108% since 2012. After 2010, the ratio of brachytherapy to prostatectomy treatment in this older age group decreased from around 1 in 2.5 to 1 in 8.

The study authors said that despite the decrease in overall treatment numbers, a higher proportion of men diagnosed with prostate cancer were receiving treatment. This likely reflected decreased PSA testing resulting in reduced prostate cancer diagnosis across Australia (decreasing from 197.4 to 140.2 per 100 000 men between 2009-2014) and a decrease in diagnosis of low-risk, or clinically insignificant cancers.

The increase in proportion of men with prostate cancer being treated was mostly attributable to an increase in prostatectomy in men aged 65– 74 years and 75– 84 years.

“The increased uptake of robotic surgery may have also contributed to the increased proportion of surgery in older men,” the authors wrote.

The use of  robot-assisted surgery in older men may have been encouraged by studies showing that they had outcomes similar to those in younger men and high rates of satisfaction, they said.

“Furthermore, side effects from radiotherapy can result in significant morbidity for patients, including local toxicity resulting in emergency admissions that may require surgery (clot evacuation, urethral dilatation) or definitive reconstructive surgery  as well as systemic toxicity from androgen deprivation therapy, which may further deter men from this choice of treatment.”

Reduced brachytherapy use may also reflect issues with funding, lack of expertise and decentralisation of radiation services as well as wider use of EBRT, they added.

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