Trends in the use of radiation therapy for stage IIA prostate cancer from 2004 to 2013: a retrospective analysis using the National Cancer Database

Changing nationwide trends away from overtreatment among patients undergoing radical prostatectomy over the past 25 years

PURPOSE

The objective of the current study was to assess whether and how preoperative risk group distribution and pathological outcomes have changed in men treated with radical prostatectomy (RP) over the past 25 years.

METHODS

11,071 patients from a large contemporary registry-based nationwide cohort with RP as primary treatment between 1995 and 2019 were included. Preoperative risk stratification, postoperative outcomes, and 10 years other-cause mortality (OCM) were analyzed.

RESULTS

After 2005, the proportion of low-risk prostate cancer (PCa) decreased from 39.6% to 25.5% in 2010 and decreased further to 15.5% in 2015, and 9.4% in 2019 (p < 0.001). The proportion of high-risk cases increased from 13.1% in 2005 to 23.1% in 2010 and 36.7% in 2015, and 40.4% in 2019 (p < 0.001). After 2005, the proportion of cases with favorable localized PCa decreased from 37.3% to 24.9% in 2010 and decreased further to 13.9% in 2015, and 1.6% in 2019 (p < 0.001). The overall 10 years OCM was 7.7%.

CONCLUSION

The current analysis documents a clear shift in utilization of RP toward higher-risk PCa in men with long life expectancy. Patients with low-risk PCa or favorable localized PCa are rarely operated. This suggests a shift in applying surgery only to patients who may really benefit from RP and the long-standing discussion of overtreatment might become outdated.

Real-world utilisation of brachytherapy boost and patient-reported functional outcomes in men who had external beam radiation therapy for prostate cancer in Australia

Background and purpose

We aimed to evaluate utilisation of brachytherapy (BT) boost in men who had external beam radiation therapy (EBRT) for prostate cancer, and to compare patient-reported functional outcomes (PRO) following each approach in a population-based setting in Australia.

Materials and methods

This is a population-based cohort of men with localised prostate cancer enrolled in the Victorian Prostate Cancer Outcomes Registry, who had EBRT between 2015 and 2020. Primary outcomes were proportion who had BT-boost, and PRO (assessed using the EPIC-26 questionnaires) 12 months post-treatment. Multivariable logistic regressions were used to evaluate factors associated with BT-boost, and linear regressions were used to estimate differences in EPIC-26 domain scores between EBRT alone and EBRT + BT.

Results

Of the 1,626 men in the study, 88 (5.4 %) had BT-boost. Factors independently associated with BT-boost were younger age, higher socioeconomic status, and treatment in public institutions. 1,555 men completed EPIC-26 questionnaires. No statistically or clinically significant differences in EPIC-26 urinary, sexual and bowel functional domain scores were observed between men who had EBRT + BT vs EBRT alone, with adjusted mean differences in urinary incontinence, urinary irritative/ obstruction, sexual, and bowel domain of 1.28 (95 %CI = -3.23 to 5.79), -2.87 (95 %CI = -6.46 to 0.73), 0.49 (95 %CI = -4.78 to 5.76), and 2.89 (95 %CI = -0.83 to 6.61) respectively.

Conclusion

1-in-20 men who had EBRT for prostate cancer had BT-boost. This is the first time that PRO following EBRT+/-BT is reported at a population-based level in Australia, with no evidence to suggest worse PRO with addition of BT-boost 12 months post-treatment.

Quality of Life Implications of Dose-Escalated External Beam Radiation for Localized Prostate Cancer: Results of a Prospective Randomized Phase 3 Clinical Trial, NRG/RTOG 0126

PURPOSE

External beam radiation therapy (EBRT) dose escalation has been tested in multiple prospective trials. However, the impact on patient reported outcomes (PROs) associated with higher doses of EBRT remain poorly understood. We sought to assess the differences in PROs between men treated with a dose of 70.2 Gy versus 79.2 Gy of EBRT for prostate cancer.

METHODS AND MATERIALS

The phase 3 clinical trial RTOG 0126 randomized 1532 patients with prostate cancer between March 2002 and August 2008 to 79.2 Gy over 44 fractions versus 70.2 Gy over 39 fractions. Eligible patients participated in the PRO data collection. PROs completed included the International Index of Erectile Function Questionnaire (IIEF), Functional Alterations due to Changes in Elimination (FACE), and the Spitzer Quality of Life Index (SQLI). The timepoints for the IIEF were collected pre-entry and at 6, 12, and 24 months. The FACE and SQLI were collected pre-entry and at 3, 6, 12, 18, and 24 months. The impact of EBRT dose to normal structures (penile bulb, rectum, and bladder) on PROs was also examined. Mixed effects models were used to analyze trends across time.

RESULTS

In total, 1144 patients completed baseline IIEF forms and of these, 56%, 64%, and 61% completed the IIEF at 6, 12, and 24 months, respectively; 1123 patients completed the FACE score at baseline and 50%, 61%, 73%, 61%, and 65% completed all 15 items for the FACE metric at timepoints of 3, 6, 12, 18, and 24 months, respectively. Erectile dysfunction at 12 months based on the single question was not significantly different between arms (38.1% for the standard dose radiation therapy arm vs 49.7% for the dose escalated radiation therapy arm; P = .051). Treatment arm (70.2 vs 79.2) had no significant impact on any PRO metrics measured across all collected domains. Comprehensive dosimetric analyses are presented and reveal multiple significant differences to regional organs at risk.

CONCLUSIONS

Compliance with PRO data collection was lower than anticipated in this phase 3 trial. Examining the available data, dose escalated EBRT did not appear to be associated with any detriment to PROs across numerous prospectively collected domains. These data, notwithstanding limitations, add to our understanding of the implications of EBRT dose escalation in prostate cancer. Furthermore, these results illustrate challenges associated with PRO data collection.

PSA: Declining utilization of prostate brachytherapy

PURPOSE

To analyze rates of brachytherapy use for prostate cancer over time and evaluate patient characteristics, demographics and factors predictive for its utilization.

METHODS

Data was retrospectively analyzed from the National Cancer Database (NCDB) for patients with localized prostate cancer treated between 2010 and 2015. Patients were included if they had biopsy confirmed localized adenocarcinoma of the prostate, were treated with radiation as definitive local therapy, and were at least 18 years old. Utilization rates of external beam radiation (EBRT), brachytherapy (BT) and combination (EBRT + BT) were evaluated over time. Univariable (UVA) and backwards elimination multivariable (MVA) analysis were performed to determine characteristics predictive for brachytherapy use.

RESULTS

We analyzed 178,837 patients with localized adenocarcinoma of the prostate treated between 2010 and 2015 with radiation therapy. During this period, the use of EBRT increased from 67% to 78%, BT (both monotherapy and combination with EBRT) decreased from 33% to 22%, BT monotherapy decreased from 25% to 16% and EBRT + BT decreased from 8% to 6%. Age >70, government funded insurance or lack of insurance, intermediate or high-risk disease and treatment at an academic center were associated with significantly lower utilization of brachytherapy (all p <0.001), while higher median zip code income was associated with increased use (p = 0.02). On multivariable analysis patients who were younger, had private insurance, were lower NCCN risk category and treated in non-academic cancer centers, had a higher rate of brachytherapy utilization. Notably, on both UVA and MVA brachytherapy practice decreased with increasing year of diagnosis (OR 0.881, 95% CI 0.853-0.910, p <0.001).

CONCLUSION

Rates of brachytherapy utilization for the treatment of prostate cancer continue to decrease over time. Treatment at an academic center was associated with reduced likelihood of brachytherapy use. This has significant implications for the training of future radiation oncology residents/fellows and direct consequences for both our patients and healthcare expenditure.

Consulting "Dr. Google" for Prostate Cancer Treatment Options: A Contemporary Worldwide Trend Analysis

BACKGROUND

In the era of digital data, the Internet has become the primary source from which individuals draw healthcare information.

OBJECTIVE

The aim of the present study is to determine worldwide public interest in prostate cancer (PCa) treatments, their penetrance and variation, and how they compare over time.

DESIGN, SETTING, AND PARTICIPANTS

An analysis of worldwide search-engine trends included electronic Google queries from people who searched PCa treatment options from January 2004 to August 2018, worldwide. Join-point regression was performed. Comparisons of annual relative search volume (ARSV), average annual percentage change (AAPC), and temporal patterns were analysed to assess loss or gain of interest.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Evaluations were made regarding (1) interest in PCa treatments, (2) comparison of people's interest, and (3) impact of the US Preventive Service Task Force (USPSTF) screening recommendation and National Comprehensive Cancer Network (NCCN) guideline endorsements on Internet searching for PCa treatments.

RESULTS AND LIMITATIONS

The mean ARSV for "prostatectomy" was 73% in 2004 and decreased thereafter, reaching a nadir of 36% in 2014 (APC: -7.2%; 95% confidence interval [CI] -7.8, -6.7; p < 0.01). Similarly, decreased interest was recorded for radiation therapy (AAPC: -3.2%; p = 0.1), high-intensity focused ultrasound (AAPC: -2.3%; p = 0.1), hormonal therapy (AAPC: -11.6%; p < 0.01), ablation therapy (AAPC: -4.1%; p < 0.01), cryotherapy (AAPC: -9.9%; p < 0.01), and brachytherapy (AAPC: -8.3%; p < 0.01). A steep interest was found in active surveillance (AS) (AAPC: +14.2%; p < 0.01) and focal therapy (AAPC: +27.5%; p < 0.01). When trends were compared before and after NCCN and USPSTF recommendations, a consistent decrease of all the treatment options was found, while interest in focal therapy and AS showed an augmented mean ARSV (+19.6 and +31.6, respectively).

CONCLUSIONS

People are increasingly searching the Internet for PCa treatment options. A parallel decrease of interest was found for the nonmonitoring treatments, except for focal therapy, while an important growth of appeal has been recorded for AS. Understanding people inquisitiveness together with their degree of knowledge could be supportive to guiding counselling in the decision-making process and putting effort in certifying patient information.

PATIENT SUMMARY

In the era of digital data, patients are increasingly searching the Internet for prostate cancer (PCa) treatment options. To safeguard patients' knowledge, it is mandatory to understand how people seek healthcare information, guaranteeing certified and evidence-based information pertaining to PCa treatments options.

Oncological impact of neoadjuvant hormonal therapy on permanent iodine-125 seed brachytherapy in patients with low- and intermediate-risk prostate cancer

OBJECTIVES

To determine whether neoadjuvant hormonal therapy improves oncological outcomes of patients with localized prostate cancer treated with permanent brachytherapy.

METHODS

Between January 2004 and November 2014, 564 patients underwent transperineal ultrasonography-guided permanent iodine-125 seed brachytherapy. We retrospectively analyzed low- or intermediate-risk prostate cancer based on the National Comprehensive Cancer Network guidelines. The clinical variables were evaluated for influence on biochemical recurrence-free survival, progression-free survival, cancer-specific survival and overall survival.

RESULTS

A total of 484 patients with low-risk (259 patients) or intermediate-risk disease (225 patients) were evaluated. Of these, 188 received neoadjuvant hormonal therapy. With a median follow up of 71 months, the 5-year actuarial biochemical recurrence-free survival rates of patients who did and did not receive neoadjuvant hormonal therapy were 92.9% and 93.6%, respectively (P = 0.2843). When patients were stratified by risk group, neoadjuvant hormonal therapy did not improve biochemical recurrence-free survival outcomes in low- (P = 0.8949) or intermediate-risk (P = 0.1989) patients. The duration or type of hormonal therapy was not significant in predicting biochemical recurrence. In a multivariate analysis, Gleason score, pretreatment prostate-specific antigen, clinical T stage, and prostate dosimetry, primary Gleason score and positive core rate were significant predictive factors of biochemical recurrence-free survival, whereas neoadjuvant hormonal therapy was insignificant. Furthermore, neoadjuvant hormonal therapy did not significantly influence progression-free survival, cancer-specific survival or overall survival.

CONCLUSIONS

In patients with low- or intermediate-risk disease treated with permanent prostate brachytherapy, neoadjuvant hormonal therapy does not improve oncological outcomes. Its use should be restricted to patients who require prostate volume reduction.