Prostatectomy Rates to Treat High-Risk Prostate Cancer Have Nearly Doubled

An analysis observed a significant surge in prostatectomies in high-risk prostate cancer patients over a 12-year period, nearly matching that of radiotherapy, which sharply declined during the same time period.

The study, published in JAMA Network Open, evaluated data from the National Cancer Database (NCDB) spanning 2004 through 2016. The NCDB houses data on more than 70% of new cancer diagnoses in the U.S.; the present analysis included men diagnosed with high-risk prostate cancer, defined as: clinical stage T3 to T4, a prostate-specific antigen level >20 ng/mL, or a Gleason score between 8 and 10.

Final analysis included 214,972 men; 79.2% were white, and 16.1% were black. More than half of the patients had government-based insurance (59.3%); about 82% of patients had a Charlson-Deyo comorbidity index of 0. The rate of high-risk prostate cancer nearly doubled over the study period, from 11.8% to 20.4% (P<0.001).

Although a slightly higher proportion of patients underwent radiotherapy (n=104,635) than prostatectomy (n=75,847), high-risk prostate cancer treatment trends shifted overtime, the researchers observed. At the beginning of the study period, 22.8% of men received prostatectomy; this rate jumped to 40.5% at the end of the study period (P<0.001). Meanwhile, men became less likely to undergo radiotherapy by the end of the study period, with the rate dropping from 59.7% to 43.3% (P<0.001). The most significant increase in prostatectomies was observed from 2004 to 2013, after which rates remained fairly stable. In 2016, the odds ratio of undergoing radical prostatectomy compared to in 2004 was 2.72 (95% confidence interval, 2.56 to 2.88). Trends were similar between black and white high-risk patients; although white men were more likely than black men to undergo prostatectomy, the disparity improved overtime, the researchers observed. Among the radiotherapy patients, 12.6% received external beam radiation therapy with a brachytherapy boost.

Factors associated with robotic prostatectomy were higher income, private insurance, and receiving treatment at an academic facility, the researchers wrote.

“The increase in prostatectomies may reflect increasing acceptance of population-based data suggesting superiority of prostatectomy. The increasing use of robotic approaches suggests urologists and patients may regard prostatectomies safer than previous techniques. Conversely, a decrease in radiotherapy may reflect reluctance toward recommended androgen deprivation therapy with radiotherapy,” they theorized.

The study authors noted that there are no randomized data to suggest that prostatectomy is superior to radiotherapy in high-risk prostate cancer patients—nor do they expect to see these data in the future. Previous studies have either focused on low- or intermediate-risk patients, or have only had small sample of high-risk patients.

“Men may prefer prostatectomy given the treatment burden of radiotherapy, which may change with shortened schedules,” the researchers wrote in their conclusion.