[Treatment costs of localized prostate cancer in Germany : Economic results from the HAROW observational study]

Radical prostatectomy versus deferred treatment for localised prostate cancer

BACKGROUND

Prostate cancer is a common cancer but is oftentimes slow growing. When confined to the prostate, radical prostatectomy (RP), which involves removal of the prostate, offers potential cure that may come at the price of adverse events. Deferred treatment, involving observation and palliative treatment only (watchful waiting (WW)) or close monitoring and delayed local treatment with curative intent as needed in the setting of disease progression (active monitoring (AM)/surveillance (AS)) might be an alternative. This is an update of a Cochrane Review previously published in 2010.

OBJECTIVES

To assess effects of RP compared with deferred treatment for clinically localised prostate cancer.

SEARCH METHODS

We searched the Cochrane Library (including CDSR, CENTRAL, DARE, and HTA), MEDLINE, Embase, AMED, Web of Science, LILACS, Scopus, and OpenGrey. Additionally, we searched two trial registries and conference abstracts of three conferences (EAU, AUA, and ASCO) until 3 March 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared RP versus deferred treatment in patients with localised prostate cancer, defined as T1-2, N0, M0 prostate cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of references and extracted data from included studies. The primary outcome was time to death from any cause; secondary outcomes were: time to death from prostate cancer; time to disease progression; time to metastatic disease; quality of life, including urinary and sexual function; and adverse events. We assessed the certainty of evidence per outcome using the GRADE approach.  MAIN RESULTS: We included four studies with 2635 participants (average age between 60 to 70 years). Three multicentre RCTs, from Europe and USA, compared RP with WW (n = 1537), and one compared RP with AM (n = 1098). Radical prostatectomy versus watchful waiting RP probably reduces the risk of death from any cause (hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.70-0.90; 3 studies with 1537 participants; moderate-certainty evidence). Based on overall mortality at 29 years, this corresponds to 764 deaths per 1000 men in the RP group compared to 839 deaths per 1000 men in the WW group. RP probably also lowers the risk of death from prostate cancer (HR 0.57, 95% CI 0.44-0.73; 2 studies with 1426 participants; moderate-certainty evidence). Based on prostate cancer-specific mortality at 29 years, this corresponds to 195 deaths from prostate cancer per 1000 men in the RP group compared with 316 deaths from prostate cancer per 1000 men in the WW group. RP may reduce the risk of progression (HR 0.43, 95% CI 0.35-0.54; 2 studies with 1426 participants; I² = 54%; low-certainty evidence); at 19.5 years, this corresponds to 391 progressions per 1000 men for the RP group compared with 684 progressions per 1000 men for the WW group) and probably reduces the risk of developing metastatic disease (HR 0.56, 95% CI 0.46-0.70; 2 studies with 1426 participants; I² = 0%; moderate-certainty evidence); at 29 years, this corresponds to 271 metastatic diseases per 1000 men for RP compared with 431 metastatic diseases per 1000 men for WW. General quality of life at 12 years' follow-up is probably similar for both groups (risk ratio (RR) 1.0, 95% CI 0.85-1.16; low-certainty evidence), corresponding to 344  patients with high quality of life per 1000 men for the RP group compared with 344 patients with high quality of life per 1000 men for the WW group. Rates of urinary incontinence may be considerably higher (RR 3.97, 95% CI 2.34-6.74; low-certainty evidence), corresponding to 173 incontinent men per 1000 in the RP group compared with 44 incontinent men per 1000 in the WW group, as are rates of erectile dysfunction (RR 2.67, 95% CI 1.63-4.38; low-certainty evidence), corresponding to 389 erectile dysfunction events per 1000 for the RP group compared with 146 erectile dysfunction events per 1000 for the WW group, both at 10 years' follow-up. Radical prostatectomy versus active monitoring Based on one study including 1098 participants with 10 years' follow-up, there are probably no differences between RP and AM in time to death from any cause (HR 0.93, 95% CI 0.65-1.33; moderate-certainty evidence). Based on overall mortality at 10 years, this corresponds to 101 deaths per 1000 men in the RP group compared with 108 deaths per 1000 men in the AM group. Similarly, risk of death from prostate cancer probably is not different between the two groups (HR 0.63, 95% CI 0.21-1.89; moderate-certainty evidence). Based on prostate cancer-specific mortality at 10 years, this corresponds to nine prostate cancer deaths per 1000 men in the RP group compared with 15 prostate cancer deaths per 1000 men in the AM group. RP probably reduces the risk of progression (HR 0.39, 95% CI 0.27-0.56; moderate-certainty evidence; at 10 years, this corresponds to 86 progressions per 1000 men for RP compared with 206 progressions per 1000 men for AM) and the risk of developing metastatic disease (RR 0.39, 95% CI 0.21-0.73; moderate-certainty evidence; at 10 years, this corresponds to 24 metastatic diseases per 1000 men for the RP group compared with 61 metastatic diseases per 1000 men for the AM group).The general quality of life during follow-up was not different between the treatment groups. However, urinary function (mean difference (MD) 8.60 points lower, 95% CI 11.2-6.0 lower) and sexual function (MD 14.9 points lower, 95% CI 18.5-11.3 lower) on the Expanded Prostate Cancer Index Composite-26 (EPIC-26) instrument, were worse in the RP group.

AUTHORS' CONCLUSIONS

Based on long-term follow-up, RP compared with WW probably results in substantially improved oncological outcomes in men with localised prostate cancer but also markedly increases rates of urinary incontinence and erectile dysfunction. These findings are largely based on men diagnosed before widespread PSA screening, thereby limiting generalisability. Compared to AM, based on follow-up to 10 years, RP probably has similar outcomes with regard to overall and disease-specific survival yet probably reduces the risks of disease progression and metastatic disease. Urinary function and sexual function are probably decreased for the patients treated with RP.

[Noninvasive treatment of organ-confined prostate cancer in elderly patients-results of the HAROW study]

BACKGROUND

Noninvasive treatment options such as active surveillance (AS), watchful waiting (WW), and hormone deprivation therapy (HT) are particularly important in elderly patients with localized prostate cancer (PCa).

OBJECTIVES

We examine the use of these noninvasive treatment options in the everyday care in a cohort of patients ≥70 years old.

MATERIALS AND METHODS

In the HAROW study, the treatment of localized PCa under everyday conditions is investigated. The only inclusion criterion was newly diagnosed organ-confined PCa (≤cT2c). In AS, WW, and HT patients, we compared initial tumor and patient characteristics, follow-up examinations and changes of therapy.

RESULTS

Of 457 patients ≥70 years, 210 chose AS, 160 HT, and 87 WW. Observation times were 6.3 years (AS), 7.5 years (HT), and 7.0 years (WW). AS patients (73.2 years) were younger than WW (76.0 years) and HT patients (76.9 years) and had a higher proportion of low-risk tumors (80%) versus WW (31%) and HT (19%). A change of therapy was observed in 47.1% of AS, 17.2% of WW and 13.1% of HT patients. Metastasis occurred in 1.0% of AS, 4.6% of WW, and 6.9% of HT patients. Overall survival was 94.3% for AS, 90.8% for WW and 81.9% for HT. Within the first 28.4 months, the mean number of PSA determinations did not differ between AS and WW (6.1 vs. 5.2; p = 0.09); a rebiopsy was performed in 37.6% of AS, 11.4% of WW, and 17% of HT patients.

CONCLUSIONS

The allocation to curative and palliative strategies should be made according to patient and tumor characteristics by definition. Palliative procedures may represent concepts in older patients who initially chose a curative AS strategy.

Passive-specific immunotherapy with monoclonal antibodies for prostate cancer: A systematic review

Introduction

Treatment of metastatic castration-resistant prostate cancer with conventional therapies is still not successful. Therefore, application of novel biological approaches such as immunotherapy, which appears to be more effective and less toxic, is necessary. Monoclonal antibodies against cancer specific antigens are a kind of immunotherapy that have been approved for specific types of cancer and are being investigated for prostate cancer as well. The aim of this review was to assess the effectiveness and safety of monoclonal antibodies for treatment of advanced prostate cancer.

Method

According to the search strategy stated in our systematic review protocol, Scopus, Medline, TRIP, CENTRAL, ProQuest, DART and OpenGrey databases were searched. Data collection and quality assessment were done independently by two authors and any disagreements between the collected data were resolved by a third author. A meta-analysis was not feasible as there was a considerable statistical heterogeneity among the trials. Hence, this review was limited to a narrative analysis of the included studies.

Results

We found 9756 references by applying search strategy in 4 databases of journal articles and 3 databases of grey literature. We then discarded 3957 duplicate citations using Endnote software and 5143 articles due to obvious irrelevancy of their topics in primary screening. In secondary screening of 656 fulltexts, we excluded 538 articles, and finally included 12 trials in this systematic review, updated on 23 June 2017. The overall quality of the studies was fair. In general, results of this systematic review show promising advances in the treatment of prostate cancer patients with monoclonal antibodies against prostate-specific antigens with regard to PSA/disease response. Some of the studies reported pain relief after treatment as well.

Conclusion

Currently, the role of immunotherapy in the treatment of advanced prostate cancer still remains debated. Although passive specific immunotherapy could be offered as a novel therapeutic option in the coming years, patients should be informed about the risks and benefits of this therapy. One of the obstacles in this review was the lack of adequate assessment of survival-related endpoints reported in the included studies. Our study provides support for further research in this field.

Health services research in German radiation oncology: new opportunities to advance cancer care

BACKGROUND

Health services research (HSR) is of increasing relevance to scientists, health-care providers, and clinicians. Complex population-based secondary data are a key source of information for analyses of health-care effects in radiation oncology.

METHODS

In this short paper, we examine potential applications of secondary data focusing on statistics from the diagnosis-related groups (DRG). This data set incorporating all hospitalized cases in Germany is based on claims of reimbursements and is provided by the Research Data Centers (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states. A short outlook regarding other data sources is also presented.

RESULTS

In radiation oncology, secondary data such as the DRG statistics have rarely been used to examine health-care effects, despite their great potential for reporting effects in a broad population-based setting. Furthermore, for most data sources, the application to use these data is accessible with minor effort. However, data concerning outpatient care are difficult to analyze on a comparable level.

CONCLUSION

DRG statistics and related secondary data provide a remarkable source of information for analyses of health-care-related effects in radiation oncology.