Original article
Significant increase in prostatectomy and decrease in radiation for clinical T3 prostate cancer from 1998 to 2012

https://doi.org/10.1016/j.urolonc.2015.09.002Get rights and content

Highlights

  • We describe how treatment patterns have changed for clinical T3 prostate cancer.

  • Rates of prostatectomy increased significantly from 1998 to 2012 (12.5% vs. 44.4%).

  • Rates of radiation decreased significantly from 1998 to 2012 (55.8% vs. 38.4%).

  • By 2012, rates of prostatectomy surpassed rates of radiation.

Abstract

Purpose

We aimed to describe changes in treatment patterns for clinical T3 prostate cancer (PCa) from 1998 to 2012, specifically investigating what factors influence receipt of prostatectomy or radiation.

Materials and methods

Using the Surveillance, Epidemiology, and End Results database, we studied 11,604 men with clinical T3N0M0 PCa from 1998 to 2012, with treatment categorized as radiation, radical prostatectomy (RP), or no curative therapy. We calculated rate of treatment type by year of diagnosis to investigate trends in treatment patterns, further stratifying by clinical T3a, defined as unilateral and bilateral extracapsular extension (n = 3,842), vs. T3b (defined as extension to seminal vesicles (n = 3,665). Finally, a multivariable logistic regression analysis measured association of demographic and clinical variables with type of treatment received for years 2010 to 2011.

Results

Rates of prostatectomy increased significantly from 1998 to 2012 (12.5% vs. 44.4%), radiation decreased significantly (55.8% vs. 38.4%), and receipt of no treatment also decreased (31.7% vs. 17.2%, all P<0.001). These trends were similar for clinical T3a and T3b. Rates of prostatectomy surpassed radiation by 2008 in clinical T3a, reaching 49.8% vs. 37.1%, respectively, in 2012 (P = 0.002), and were statistically similar to radiation in 2012 for clinical T3b, reaching 41.6% vs. 42.1% (P = 0.92). Multivariable logistic regression analysis demonstrated that patients were less likely to receive prostatectomy than radiation if biopsy Gleason scores of 8 to 10 (adjusted odds ratio [AOR] = 0.41, 0.32–0.53), higher initial prostate-specific antigen (AOR = 0.97, 0.97–0.98), and older age (AOR = 0.92, 0.90–0.03, all P<0.01). The likelihood of RP was similar among cT3b vs. cT3a (AOR = 0.95, 0.71–1.26, P = 0.74).

Conclusions

Since 1998, there has been a significant increase in the use of RP for clinical T3 PCa and a significant decrease in the use of radiation such that in 2012, the use of prostatectomy exceeded the use of radiation.

Introduction

Radiation and long-term androgen deprivation therapy (ADT) has been a standard of care for clinical T3 prostate cancer (PCa) since the 1997 publication of the EORTC 22863 trial by Bolla et al. [1] demonstrating that combination radiation therapy (RT) with 3 years of ADT improved overall survival compared with RT alone. Beginning with the 1999 National Comprehensive Cancer Network (NCCN) guidelines, radical prostatectomy (RP) was listed as an acceptable treatment for small, low-grade, clinical T3 PCa [2]. Since then, publication of the Swedish prostatectomy randomized trial showing a survival benefit for men with clinically localized PCa may have increased enthusiasm for RP in even locally advanced disease [3]. Several retrospective studies have also reported good biochemical recurrence-free survival and cancer-specific survival rates following RP for patients with T3b disease [4], [5], [6]. In this study, we aim to investigate how the proportion of patients receiving RP vs. RT changed from 1998 to 2012 for clinical T3 PCa, as well as identify what demographic and clinical factors influence receipt of RP and RT.

Section snippets

Patient selection

The Surveillance, Epidemiology, and End Results (SEER) database is a population-based, cancer registry that collects demographic characteristics and cancer diagnostic, treatment, and survival data [7]. SEER covers 18 U.S. regions, including approximately 28% of the US population. Using SEER⁎Stat 8.1.5, we extracted data on 12,815 men diagnosed with clinical T3, histologically confirmed prostatic adenocarcinoma between 1998 and 2012. Patients with clinical T1–T2 disease who were upstaged to

Baseline patient characteristics

Table 1 lists baseline demographic and clinical characteristics for our cohort of 11,341 men with clinical T3/N0/M0 PCa. The median age overall was 67 years (range: 38–99), and 62 for RP, 68 for RT, and 75 for no curative therapy (P<0.001). Most patients were white (72.5%) and married (67.6%). For all patients, the median county-level household income was $46,680 and the median county-level percentage of adults without a high school diploma was 17.4%. Clinically, 33.1% of patients had clinical

Discussion

In this study of 11,604 men with cT3N0M0 PCa from 1998 to 2012, we found that rates of prostatectomy (RP) significantly increased from 12.5% to 44.4% over the study period, whereas the rates of RT greatly decreased from 55.8% to 38.4%. In 2012, the overall rate of RP was significantly higher than RT for clinical T3 patients (cT3, 44.4% vs. 38.4%, P = 0.023). Rates of RP have surpassed RT since 2008 in cT3a disease and were statistically similar to RT in 2012 for cT3b. This strong trend towards

Conclusion

Since 1998, there has been a significant increase in the use of RP for clinical T3 PCa and a significant decrease in the use of radiation such that in 2012, the use of prostatectomy exceeded the use of radiation. There is a need for further prospective work to identify what subgroups of locally advanced patients with PCa may be best served by prostatectomy vs. radiation.

Acknowledgments

This work is supported financially by Fitz׳s Cancer Warriors, David and Cynthia Chapin, the Prostate Cancer Foundation, Hugh Simons in honor of Frank and Anne Simons, Scott Forbes and Gina Ventre, The Campbell Family in Honor of Joan Campbell, and a grant from an anonymous family foundation. All listed authors were involved in the design, data analysis, and manuscript preparation, and all authors approved the final version of this paper. Paul L. Nguyen has consulted for Medivation and GenomeDX.

References (37)

  • P. Warde et al.

    Combined androgen deprivation therapy and radiation therapy for locally advanced prostate cancer: a randomised, phase 3 trial

    Lancet

    (2011)
  • N.N. Stone et al.

    Local control following permanent prostate brachytherapy: effect of high biologically effective dose on biopsy results and oncologic outcomes

    Int J Radiat Oncol Biol Phys

    (2010)
  • S.B. Williams et al.

    Economics of robotic surgery: does it make sense and for whom?

    Urol Clin North Am

    (2014)
  • O. Bratt et al.

    Undertreatment of men in their seventies with high-risk nonmetastatic prostate cancer

    Eur Urol

    (2015)
  • W. Underwood et al.

    Racial/ethnic disparities in the treatment of localized/regional prostate cancer

    J Urol

    (2004)
  • M. Bolla et al.

    Improved survival in patients with locally advanced prostate cancer treated with radiotherapy and goserelin

    N Engl J Med

    (1997)
  • C. Logothetis et al.

    Update: NCCN Practice Guidelines for the treatment of prostate cancer

    Oncology

    (1999)
  • A. Bill-Axelson et al.

    Radical prostatectomy versus watchful waiting in early prostate cancer

    N Engl J Med

    (2005)
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