Utilization and survival outcomes between definitive versus conservative treatments among elderly men with high-risk prostate cancer.

2021 ◽  
Vol 39 (6_suppl) ◽  
pp. 204-204
Author(s):  
Sagar Anil Patel ◽  
Hiram Alberto Gay ◽  
Jeff M. Michalski ◽  
Brian Christopher Baumann ◽  
Randall Brenneman ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Treatment Modality ◽  
Local Treatment ◽  
Local Therapy ◽  
The United States ◽  
Definitive Treatment ◽  
Survival Outcomes ◽  
Elderly Men ◽  
Primary Treatment Modality

204 Background: Prostate cancer (PCa) is the second leading cause of cancer death in men > 80 years old. However, studies have shown that older men are less likely to undergo curative treatment for localized PCa, possibly due to competing comorbidities or inability to accurately estimate life expectancy. Herein, we investigate utilization trends and survival outcomes amongst guideline-supported treatment options in elderly men with high-risk PCa in the United States. Methods: Men ≥ 80 years diagnosed with high-risk PCa (cT3-4 or Gleason 8-10 or PSA > 20) between 2004-2016 were analyzed from the National Cancer Database. Those missing risk-stratification or treatment data were excluded. Eligible patients were grouped based on their primary treatment modality: no treatment (observation), androgen deprivation therapy (ADT) alone, radiation therapy (RT) alone, RT + ADT, or radical prostatectomy (RP). Cochran-Armitage was used to evaluate treatment trends over time, and multivariable logistic regression was used to identify sociodemographic predictors of treatment. Overall survival (OS) between treatments was evaluated using Kaplan-Meier, log-rank, and multivariable Cox proportional hazards. Results: With a median follow up of 42 months, 19,920 men were eligible for analysis. The most utilized treatment modality was RT+ADT (37.2%), followed by ADT alone (29.4%), observation (23.9%), RT alone (7.8%), and RP (1.7%). There was a significant increase in use of RT+ADT and RT alone (p < 0.001) and decrease in use of ADT alone and observation ( p< 0.001); no change was seen in RP use. There was no OS difference between observation versus ADT alone (aHR 1.04, 95% CI 0.99-1.09, p = 0.11). Definitive local treatment was associated with improved OS compared to ADT alone (RT+ADT: aHR 0.48, 95% CI 0.46-0.50, p < 0.0001; RT alone: aHR 0.54, 95% CI 0.50-0.59, p < 0.0001; RP: aHR 0.50, 95% CI 0.42-0.59, p < 0.0001). Black men and uninsured status were independently associated with lower likelihood of undergoing definitive treatment (i.e. RT+ADT, RT, or RP). Conclusions: For men ≥ 80 years old with high-risk PCa in this large US registry, definitive local therapy using RT +/- ADT or RP was associated with a 50% reduction in overall mortality compared to observation or ADT alone. Less than half of men in this time period underwent a definitive treatment, and Black and uninsured men remained at particularly high risk of undertreatment.

Contemporary trends in receipt of local therapy for men with clinically localized high-risk prostate cancer.

2015 ◽  
Vol 33 (7_suppl) ◽  
pp. 111-111 ◽  
Author(s):  
Lora S Wang ◽  
Elizabeth Handorf ◽  
Colin T. Murphy ◽  
Mohammed Haseebuddin ◽  
Nikhil Waingankar ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Private Insurance ◽  
Local Treatment ◽  
Local Therapy ◽  
Background Level ◽  
Primary Treatment ◽  
High Risk Prostate Cancer ◽  
Risk Prostate Cancer ◽  
To Receive

111 Background: Level I evidence suggests local treatment results in improved survival as compared to androgen deprivation therapy (ADT) alone or watchful waiting for high risk prostate cancer (CaP), but contemporary trends in primary treatment for high risk CaP are poorly understood. Our aim is to examine local therapy utilization for patients with high risk CaP using a large national cancer registry. Methods: Using the National Cancer Database (NCDB), patients with clinically localized CaP meeting National Comprehensive Cancer Network high risk criteria were identified from 2004-2009. Men with node positive or metastatic disease were excluded. Adjusting for diagnosis year and demographic we examined the association between patient characteristics and local therapy, defined as radical prostatectomy (RP) or radiation (RT), in men with high risk CaP using logistic regression models. Results: A total of 132,369 men met inclusion criteria with 80% receiving local therapy and 12% receiving no treatment. There was a small but significant increase in local therapy utilization from 2004-2009 (79 to 81%, p<0.001) with the largest changes seen in increased use of RP alone (24 to 31%, p<0.001) and decreased use of RT+ADT (33 to 29%, p<0.001). In comparison, minor changes were noted in the rates of RT alone (14 to 13%, p=0.02), RP+RT (2.2 to 2.9%, p<0.001), RP+RT+ADT (1.6 to 1.9%, p=0.01), and ADT alone (8.9 to 7.0%, p<0.001). Following adjustment, patients with age >70 years (OR 0.27, CI 0.23-0.30) or Charlson morbidity count > 2 (OR 0.43, CI 0.39-0.46) were less likely to receive local therapy. Further, men of African American race (OR 0.7, CI 0.67-0.74) and Medicare (OR 0.82, CI 0.77-0.87) or Medicaid (OR 0.6, 0.53-0.68) insurance were less likely to receive primary treatment than Caucasian patients or those with private insurance. Conclusions: In the NCDB, 80% of men presenting with clinically localized high risk CaP undergo local therapy as part of multimodality treatment or as monotherapy, with RP overtaking RT+ADT as the primary local treatment of choice. Furthermore, racial and insurance disparities in the receipt of primary treatment are still evident, providing targets for emerging CaP quality of care initiatives.

scholarly journals Effect of Depression on Diagnosis, Treatment, and Mortality of Men With Clinically Localized Prostate Cancer

2014 ◽  
Vol 32 (23) ◽  
pp. 2471-2478 ◽  
Author(s):  
Sandip M. Prasad ◽  
Scott E. Eggener ◽  
Stuart R. Lipsitz ◽  
Michael R. Irwin ◽  
Patricia A. Ganz ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Depressive Disorder ◽  
Expectant Management ◽  
The United States ◽  
Localized Prostate Cancer ◽  
Definitive Treatment ◽  
Median Income ◽  
Clinicopathologic Characteristics ◽  
Definitive Therapy

Purpose Although demographic, clinicopathologic, and socioeconomic differences may affect treatment and outcomes of prostate cancer, the effect of mental health disorders remains unclear. We assessed the effect of previously diagnosed depression on outcomes of men with newly diagnosed prostate cancer. Patients and Methods We performed a population-based observational cohort study using Surveillance, Epidemiology, and End Results-Medicare linked data of 41,275 men diagnosed with clinically localized prostate cancer from 2004 to 2007. We identified 1,894 men with a depressive disorder in the 2 years before the prostate cancer diagnosis and determined its effect on treatment and survival. Results Men with depressive disorder were older, white or Hispanic, unmarried, resided in nonmetropolitan areas and areas of lower median income, and had more comorbidities (P < .05 for all), but there was no variation in clinicopathologic characteristics. In adjusted analyses, men with depressive disorder were more likely to undergo expectant management for low-, intermediate-, and high-risk disease (P ≤ .05, respectively). Conversely, depressed men were less likely to undergo definitive therapy (surgery or radiation) across all risk strata (P < .01, respectively). Depressed men experienced worse overall mortality across risk strata (low: relative risk [RR], 1.86; 95% CI, 1.48 to 2.33; P < .001; intermediate: RR, 1.25; 95% CI, 1.06 to 1.49; P = .01; high: RR, 1.16; 95% CI, 1.03 to 1.32; P = .02). Conclusion Men with intermediate- or high-risk prostate cancer and a recent diagnosis of depression are less likely to undergo definitive treatment and experience worse overall survival. The effect of depression disorders on prostate cancer treatment and survivorship warrants further study, because both conditions are relatively common in men in the United States.

Prostate cancer–specific mortality and competing causes of mortality among elderly men after local therapy for prostate cancer.

2012 ◽  
Vol 30 (5_suppl) ◽  
pp. 103-103
Author(s):  
Maria Carmen Mir ◽  
Joseph C. Klink ◽  
Brandon Isariyawongse ◽  
Adam Stuart Kibel ◽  
Eric A. Klein ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Radical Prostatectomy ◽  
Local Therapy ◽  
Elderly Men ◽  
Healthy Men ◽  
Specific Mortality ◽  
Causes Of Mortality ◽  
Cancer Specific Mortality ◽  
Competing Causes

103 Background: The benefit of definitive local therapy among elderly patients (> 65 years) with localized prostate cancer (PC) is uncertain, particularly for those with comorbid illness. Despite this uncertainty, the majority of these men currently receive local therapy. We analyzed the risk of prostate cancer-specific mortality (PCSM) relative to competing causes of mortality (CCM), stratified by disease severity and comorbidity, among contemporary men treated at two high-volume hospitals Methods: Between 1995-2005, 4237 consecutive men aged 65 years or older were managed by radical prostatectomy (N = 1634), external-beam radiotherapy (N = 1570), or brachytherapy (N = 1033) at Cleveland Clinic or Barnes-Jewish Hospital. Clinical information was obtained from prospective data bases. Comorbidity was assessed using ACE-27 and Charlson Comorbidity indices. PC risk was classified according to D’Amico criteria. Fine and Gray competing risk analysis was used to assess PCSM and CCM at 10 years. Results: Over a median follow-up of 72 months (IQR: 46-97), 88 and 748 PCSM and CCM events were observed. Among healthy men with low risk PC, 10 year PCSM was 2% and CCM was 19%. Among healthy men with high risk PC, PCSM was 11% and CCM was 27%. In the group with moderate-to-severe comorbidities, CCM was 49, 59%, and 58% and PCSM was 1%, 3%, and 21% among those with low-, intermediate- and high-risk PC, respectively. Among these unhealthy men, 26% were treated by radical prostatectomy, of whom 45% had low-risk PC and 16% had high-risk PC. Among healthy men, 41% were treated by radical prostatectomy, of whom 54% and 9% had low- and high-risk PC, respectively. Conclusions: The risk of PCSM vs. CCM for older men is low, particularly for those with moderate-to-severe comorbidity; 49-59% had died from CCM within 10 years. Current evidence suggests that local therapy for PC is associated with a 25% reduction in PCSM, at best. Thus, with active surveillance, it is unlikely that PCSM would exceed 5-7% in those with low- and intermediate-risk PC. These results should inform elderly men and physicians about the risk of PCSM and CCM when deciding upon treatment for localized PC.

Recent Advances in the Management of High-Risk Localized Prostate Cancer: Local Therapy, Systemic Therapy, and Biomarkers to Guide Treatment Decisions

2020 ◽  
pp. e241-e252
Author(s):  
Rana R. McKay ◽  
Felix Y. Feng ◽  
Alice Y. Wang ◽  
Christopher J. D. Wallis ◽  
Kelvin A. Moses
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Systemic Therapy ◽  
Local Treatment ◽  
Local Therapy ◽  
Long Term Outcome ◽  
High Risk Prostate Cancer ◽  
High Risk Disease ◽  
Risk Prostate Cancer ◽  
Localized Disease

High-risk prostate cancer accounts for approximately 15% of all prostate cancer diagnoses. Patients with high-risk disease have an increased risk of developing biochemical recurrence, metastases, and death from prostate cancer. As the optimal management of high-risk disease in patients with prostate cancer continues to evolve, the contemporary treatment paradigm is moving toward a multidisciplinary integrated approach of systemic and local therapy for patients with high-risk disease. The strategies for definitive, adjuvant, and salvage local treatment, including radical prostatectomy or radiation therapy, serve as the backbone of therapy for patients with localized disease. Systemic therapy decisions regarding use in combination with surgery, choice of therapy (hormone therapy, chemotherapy), and treatment duration continue to be refined. As more effective hormonal agents populate the treatment landscape for advanced prostate cancer, including abiraterone and next-generation antiandrogens, an opportunity is provided to explore these treatments in patients with localized disease in the hope of improving the long-term outcome for patients. Integration of innovative blood and tissue-based biomarkers to guide therapy selection for patients with high-risk disease is an area of active research. Contemporary studies are using such biomarkers to stratify patients and select therapies. In this review, we summarize contemporary evidence for local treatment strategies, systemic therapy options, and biomarkers in development for the management of high-risk prostate cancer in patients.

Effect of PSA on equal treatment of high-risk patients.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e17514-e17514
Author(s):  
Basil Ferenczi ◽  
Jason Frankel ◽  
Nathan Jung ◽  
Christopher Porter ◽  
John Paul Flores
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Comparison Group ◽  
The United States ◽  
Low Risk ◽  
Definitive Treatment ◽  
Study Group ◽  
Gleason Grade ◽  
High Risk Patients ◽  
Risk Patients

e17514 Background: National Comprehensive Cancer Network (NCCN) guidelines recommend definitive treatment for high risk prostate cancer (HRPCa). This study aims to assess treatment trends for men with HRPCa, focusing on men deemed high risk on the basis of an elevated PSA alone with otherwise low risk features. Our hypothesis is that this group is treated differently than other patients with high risk disease. Methods: The National Cancer Database (NCDB) prostate cancer (PCa) participant use file was queried for high risk patients ages 18-75 with biopsy proven PCa from 2010-2016. The NCDB represents approximately 55% of men treated for PCa in the United States. Patients were divided into two groups: the study group with PSA > 20 and otherwise low risk features, and a comparison group comprised of high-risk patients due to cT stage ≥T3a or Gleason Grade Group ≥4. Patients with nodal or metastatic disease were excluded. Rates of treatment by modality were compared over the years studied. Survival was modeled using Kaplan Meier analysis. Results: 91,565 patients met eligibility criteria with 12,156 in the study group and 79,409 in the comparison group (Table). In the study group, a significantly higher number of patients underwent surveillance (10.2%) versus the comparison group (0.3%)(p < 0.001). Furthermore, there was an upward trend in use of surveillance in the study group, with a surveillance rate of 18.9% in 2016. Amongst patients receiving radiation, only 26.1% received androgen deprivation therapy (ADT) in the study group versus 82.8% in the comparison group. Despite these findings, survival analysis demonstrated significantly higher 5-year overall survival in the study group (95.1%) vs the comparison group (87.8%) (HR = 0.41, p < 0.001). Conclusions: Men categorized as HRPCa by PSA alone with otherwise low risk features are treated less aggressively than other high-risk patients with significantly higher rates of surveillance and radiation without ADT. However, these men appear to have better survival outcomes than other high-risk patients at 5-year follow-up. [Table: see text]

scholarly journals Observation with or without late radiotherapy is equivalent to early radiotherapy in high-risk prostate cancer after radical prostatectomy: A SEER-Medicare analysis on trends, survival outcomes and complications

2019 ◽  
Author(s):  
Young Suk Suk Kwon ◽  
Wei Wang ◽  
Arnav Srivast ◽  
Thomas L Jang ◽  
Singer A Eric ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Radical Prostatectomy ◽  
Cox Regression ◽  
Survival Outcomes ◽  
Study Cohort ◽  
High Risk Prostate Cancer ◽  
Pathologic Features ◽  
Risk Prostate Cancer

Abstract Introduction: While early radiotherapy (eRT) after radical prostatectomy (RP) has shown to improve oncologic outcomes in patients with high-risk prostate cancer (PCa) in a recent clinical trial, controversy remains regarding its benefit. We aimed to illustrate national trends of post-RP radiotherapy and compare outcomes and toxicities in patients receiving eRT vs. observation with or without late radiotherapy (lRT). Methods: Utilizing the Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2001 to 2011, we identified 7557 patients with high-risk pathologic features after RP (≥ pT3N0 and/or positive surgical margins). Our study cohort was consisted of patients receiving RT within 6 months of surgery (eRT), those receiving RT after 6 months (IRT), and those never receiving RT (observation). Another subcohort, delayed RT (dRT), encompassed both IRT and observation. Trends of post-RP radiotherapy were compared using the Cochran-Armitage trend test. Cox regression models identified factors predictive of worse survival outcomes. Kaplan-Meier analyses compared the eRT and the dRT groups. Results: Among those with pathologically confirmed high-risk PCa after RP, 12.7% (n=959), 13.2% (n=1710), and 74.1% (n=4888) underwent eRT, lRT, and observation without RT, respectively. Of these strategies, the proportion of men on observation without RT increased significantly over time (p=0.004). Multivariable Cox regression model demonstrated similar outcomes between the eRT and the dRT groups. At a median follow up of 5.9 years, five-year overall and cancer-specific survival outcomes were more favorable in the dRT group, when compared to the eRT group. Radiation related toxicities, including urinary incontinence, erectile dysfunction, and urethral stricture, were higher in the eRT group when compared to the lRT group. Conclusions: Our results suggest that a blanket adoption of the eRT in high-risk PCa based on clinical trials with limited follow up may result in overtreatment of a significant number of men and expose them to unnecessary radiation toxicity.

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