High-risk prostate cancer in the United States, 1990-2007

Abstract

Objectives: This study aimed to describe national trends in presentation, management, and outcomes for men with high risk prostate cancer.

Methods: Data were abstracted from CaPSURE; 10,808 men were diagnosed between 1990 and 2007 and had complete clinical data. High-risk was defined according to the D'Amico criteria; a more restrictive definition assigned clinical stage T2c to intermediate rather than high risk. Temporal trends were assessed for patient distribution among risk groups, and within the high-risk group for individual risk factors, Kattan nomogram score, Cancer of the Prostate Risk Assessment (CAPRA) score, and primary treatment. Survival analysis stratified by CAPRA score was performed.

Results: Under the standard definition, 31.2% of the men were diagnosed with high-risk disease, and 16.9% were high-risk under the restrictive definition. This proportion has fallen over time but has been stable since 2000. Patients who would be stratified to high risk under the standard definition and to intermediate risk under the restrictive definition have better outcomes than those stratified to either intermediate or high risk under both definitions. There has been no consistent risk migration within the high-risk group over time. Treatment varies substantially with CAPRA score within the high-risk group, with higher risk men less likely to receive local therapy. Use of androgen deprivation therapy has increased over time, both as primary therapy and in conjunction with both external beam radiation and brachytherapy. Biochemical outcomes vary according to CAPRA score within the high-risk group.

Conclusions: Clinical stage T2c should not define high risk, and the high-risk group should be substratified using a multivariable instrument. There is no evidence for meaningful downward risk migration among high-risk patients over the past 15 years. At least some men in the high-risk group may be undertreated.

Figure 1. Trends in patient clinical risk stratification at time of diagnosis

Percentage of men stratified to low-, intermediate-, and high-risk groups in each year group. Patients designated as “Int/High” are those stratified to high risk using the standard definition (including T2c) and intermediate using the more restrictive definition (T3a only) of high risk. Numbers indicate aggregate totals for each group in each time period: 1990-1994, 1995-1999, 2000-2001, 2002-2003, and 2004-2007. The trend toward more low- and less high-risk disease at diagnosis was significant (P<0.001).

Figure 2. Biochemical recurrence by risk group

Kaplan-Meier curves are presented for patients stratified to low-risk, intermediate-risk, and high-risk, and for those (“Int/High”) stratified to high risk using the standard definition and intermediate risk using the more restrictive definition of high risk.

Figure 3. CAPRA distribution over time among high risk patients

Change in distribution of high-risk patients (standard definition) across CAPRA scores over time.

Figure 4. Treatment trends among high risk patients

Panel A illustrates trends over time in distribution of high risk patients (standard definition) across radical prostatectomy (RP), cryotherapy (Cryo), brachytherapy (Brachy), external-beam radiation therapy (EBRT), primary androgen deprivation therapy (ADT), and watchful waiting / active surveillance (WW). Panel B shows treatment distribution among all study patients stratified by CAPRA score.

Figure 4. Treatment trends among high risk patients

Panel A illustrates trends over time in distribution of high risk patients (standard definition) across radical prostatectomy (RP), cryotherapy (Cryo), brachytherapy (Brachy), external-beam radiation therapy (EBRT), primary androgen deprivation therapy (ADT), and watchful waiting / active surveillance (WW). Panel B shows treatment distribution among all study patients stratified by CAPRA score.

Figure 5. Biochemical recurrence by CAPRA score

Kaplan-Meier curves are presented for patients in the high risk group (standard definition), stratified by CAPRA score.