Factors influencing prostate cancer patterns of care: An analysis of treatment variation using the SEER database

Abstract

Purpose: The aim of this study is to describe the trends and factors that influence the initial treatment of men with localized prostate cancer (PC) in the United States between 2004 and 2014.

Methods and materials: The National Cancer Institute's Surveillance, Epidemiology and End Results database was used to identify patients with primary prostate adenocarcinoma between 2004 and 2014. Patients were staged in accordance with the American Joint Committee on Cancer 7th edition criteria and stratified according to the National Comprehensive Cancer Network guidelines risk group classification. Descriptive statistics describing treatment patterns by year of diagnosis, age, risk group, insurance status, and region were performed.

Results: A total of 460,311 male patients were identified with sufficient information to be categorized into National Comprehensive Cancer Network risk groups. Overall, 30.9% of patients had low-risk disease, 38.1% were intermediate risk, 20.2% were high risk, 4.4% were very high risk, 1.6% were node-positive, and 4.7% had metastatic disease. During the study period, there was a 60% decrease in brachytherapy monotherapy utilization for patients with PC, and no definitive treatment increased from 20.3% in 2004 to 26.3% in 2014. There were regional treatment variations and discrepancies in treatment by age. Radical prostatectomy was performed on a greater proportion of insured patients than patients with Medicaid or those who were uninsured, but radiation therapy and no definitive treatment was administered to a greater proportion of uninsured and Medicaid patients.

Conclusions: PC treatment shows declining trends in brachytherapy utilization, increases in conservative management, and stability of surgical procedures over time. There is wide variation by geographical region, age, and insurance status.

Figure 1

The distribution of surgical and radiation therapies among patients with National Comprehensive Cancer Network low-, intermediate-, or high-risk prostate cancer, stratified by year of treatment. The colors represent each treatment group: radical prostatectomy (red), other surgical therapy including cryotherapy, transurethral resection, laser ablation, and high-intensity focal ultrasound (black), no definitive therapy, which may include active surveillance, expectant management, or primary androgen deprivation therapy (purple), brachytherapy monotherapy (green), external beam radiation therapy (blue), and external beam radiation + brachytherapy (yellow). The patterns represent National Comprehensive Cancer Network risk groups: high risk (solid color), low risk (dark cross-hatch), and intermediate risk (light cross hatch). Androgen deprivation therapy status is unknown. The percentiles in the data table reflect the proportion of the identified therapy-risk group combination for each year. RP, radical prostatectomy.

Figure 2

The distribution of surgical and radiation therapies among all patients in the Surveillance, Epidemiology, and End Results database stratified by region and age <65 or 65 + years. The colors represent each treatment group: radical prostatectomy (red), other surgical therapy including cryotherapy, transurethral resection, laser ablation, and high-intensity focal ultrasound (black), no definitive therapy, which may include active surveillance, expectant management, or primary androgen deprivation therapy (purple), brachytherapy monotherapy (green), external beam radiation therapy (blue), and external beam radiation + brachytherapy (yellow). The solid colors represent patients aged <65 years, and the patterned color represents patients aged ≥65 years. Androgen deprivation therapy status is unknown. The percentiles in the data table reflect the proportion of the identified therapy-age group combination for each region. RP, radical prostatectomy; EBRT, external beam radiation therapy.

Figure 3

The distribution of surgical and radiation therapies among patients with National Comprehensive Cancer Network low-, intermediate-, or high-risk prostate cancer stratified by age for men treated between 2004 and 2014. The colors represent the treatment group: no radiation (black), brachytherapy monotherapy (green), external beam radiation therapy (blue), and external beam radiation + brachytherapy (yellow). The patterns represent the National Comprehensive Cancer Network risk groups: high (solid color), low (dark cross-hatch), and intermediate (light cross hatch) risk. Androgen deprivation therapy status is unknown. The percentiles in the data table reflect the proportion of the identified therapy risk-group combination for each column. The heights of all columns combined equal 100% (ie, entire cohort of National Comprehensive Cancer Network low-, intermediate-, and high-risk patients, n = 410,904). Men with very high risk National Comprehensive Cancer Network status (20,317 patients) are excluded for clarity. RP, radical prostatectomy.

Figure 4

The distribution of surgical and radiation therapies among patients stratified by insurance coverage for men treated between 2004 and 2014. The colors represent the treatment groups: radical prostatectomy (red), other surgical therapy including cryotherapy, transurethral resection, laser ablation, high-intensity focal ultrasound (black), no definitive therapy, which may include active surveillance, expectant management, or primary androgen deprivation therapy (purple), brachytherapy monotherapy (green), external beam radiation therapy (blue), and external beam radiation + brachytherapy (yellow). The percentiles in the data table reflect the proportion of the identified therapy risk group combination for each column. The heights of all columns combined equals 100%.