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Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom?
EURURO-7096; No. of Pages 2 EUROPEAN UROLOGY XXX (2016) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom? Stephen B. Williams a, Brian F. Chapin b,* a
Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA; b Department of Urology, The University of Texas
MD Anderson Cancer Center, Houston, TX, USA
Preferred treatment options for localized prostate cancer include active surveillance for patients with low-risk disease, with surgery and radiation therapies reserved for intermediate-risk and high-risk disease [1,2]. Aside from tumor characteristics, determinants such as age, race/ ethnicity, socioeconomic status, and insurance have implications for the treatments administered [3–5]. In this issue of European Urology, Gray et al [6] present temporal trends in prostate cancer care using the National Cancer Database to identify trends in care and predictors of receipt of prostate cancer care. Specifically, the authors examined temporal effects of race/ethnicity, insurance, and socioeconomic status on treatment type during the study period. They differentiated observation versus treatment (radical prostatectomy [RP], brachytherapy, or external-beam radiotherapy) according to the National Comprehensive Cancer Network guideline on stratification for disease risk. While the authors should be commended for critically evaluating determinants for observation versus treatment according to disease risk, there are a few to discuss. First, the use of observation for clinically localized prostate cancer is not guideline-recommended for low-risk prostate cancer. In the present analysis, patients in the observation category probably include those who may be on watchful waiting or active surveillance. It should be cautioned that there remains a distinct difference between watchful waiting and active surveillance, since the latter entails detailed monitored follow-up, with treatment initiated at set determinants. Furthermore, active surveillance has been recommended for men diagnosed with low-risk prostate cancer [1,2]. However, the incidence of overtreatment of
low-risk disease is well known and still prevalent, as depicted in this study, with trends for greater RP utilization for low-risk disease [7,8]. In addition to determining predictors of increased utilization of active surveillance for indolent prostate cancer, the quality of surveillance has also been questioned [9,10]. Similar to the present study, previous research using SEER-Medicare linked data revealed significantly lower utilization of watchful waiting/active surveillance [11]. Moreover, in another study evaluating the quality of active surveillance, when comparing patients undergoing active treatment, those who underwent watchful waiting/active surveillance were less likely to undergo prostate-specific antigen testing and attend office visits within the 2 yr following diagnosis (p < 0.01) [12]. Of the 3656 patients undergoing watchful waiting/active surveillance, only 166 (4.5%) were on ‘‘active surveillance’’ (according to the a priori definition). This means that the current utilization of observation for lowrisk patients reported in the present study as 21.3% at best does not accurately represent active surveillance utilization patterns; it is likely that utilization is far less and underdetermined from the present data set. Interestingly, RP utilization increased independent of risk stratification, a surrogate for tumor biology. Furthermore, RP use increased in patients with high-risk disease during the study period, when historically radiation with androgen deprivation therapy was largely administered. With the introduction of robotic prostatectomy and further data supporting the utility of surgery as the initial step in therapy among patients with high-risk disease, these findings may not be surprising. However, even patients
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2016.08.047. * Corresponding author. Department of Urology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA. Tel. +1 713 7923250; Fax: +1 713 7944824. E-mail address: [email protected] (B.F. Chapin). http://dx.doi.org/10.1016/j.eururo.2016.10.020 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Williams SB, Chapin BF. Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom? Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.020
EURURO-7096; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
with higher comorbidity (Charlson comorbidity index 1 and 2) were more likely to undergo surgery than radiotherapy. Prior reports suggested that radiotherapy patients have greater comorbidity than surgery patients, with greater risk of perioperative complications and hospitalization [13,14]. Whether the increased trend for surgery among high-risk patients with greater comorbidity results in oncologic superiority with acceptable perioperative morbidity when compared to radiotherapy remains to be determined. Equally, with increasing understanding of the need for a multimodal approach to high-risk prostate cancer, whether surgery was the initial step (before adjuvant radiation and/or systemic therapy) and used to provide pathologic drivers for selecting appropriate secondary therapies is unclear, and may account for the increase in its utilization. Regardless of treatment, comorbidities and overall life expectancy should be taken into consideration when deciding on treatment and need to be discussed in the treatment decision-making process. Lastly, racial/ethnic disparities in prostate cancer care have previously been demonstrated. Moreover, the impact of insurance and socioeconomic status on cancer care represents hallmarks for improvement in current health care reform measures. The study findings have important implications for current decision-making aimed at improving health care through the Affordable Care Act (ACA) [15]. Over the next 10 yr, the ACA will bring in 37 million newly insured individuals, many of whom had limited access to insurance, cancer diagnosis, and treatment options, as well as those with more advanced cancer [15]. Moreover, the ACA provides significant consumer protections important to oncology patients, such as coverage of pre-existing conditions and mandated coinsurance limitations [15]. Leveling the access to care and minimizing the racial and socioeconomic disparities that exist will need to be a priority when evaluating the strategy of the ACA. In conclusion, the authors present a temporal trend for prostate cancer care in the USA that demonstrates greater utilization of RP across all risk categories, which needs to be interpreted in the context of the study design. Conflicts of interest: The authors have nothing to disclose.
References [1] Mohler JL, Armstrong AJ, Bahnson RR, et al. Prostate cancer, version 1.2016. J Natl Compr Cancer Netw 2016;14:19–30. [2] Heidenreich A, Bastian PJ, Bellmunt J, et al. EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent — update 2013. Eur Urol 2014;65:124–37. [3] Schmid M, Meyer CP, Reznor G, et al. Racial differences in the surgical care of Medicare beneficiaries with localized prostate cancer. JAMA Oncol 2016;2:85–93. [4] Wang EH, Yu JB, Abouassally R, et al. Disparities in treatment of patients with high-risk prostate cancer: results from a populationbased cohort. Urology 2016;95:88–94. [5] Williams SB, Prasad SM, Weinberg AC, et al. Trends in the care of radical prostatectomy in the United States from 2003 to 2006. BJU Int 2011;108:49–55. [6] Gray PJ, Lin CC, Cooperberg MR, Jemal A, Efstathiou JA. Temporal trends and the impact of race, insurance, and socioeconomic status in the management of localized prostate cancer. http://dx.doi.org/ 10.1016/j.eururo.2016.08.047. [7] Heidenreich A, Aus G, Bolla M, et al. EAU guidelines on prostate cancer. Eur Urol 2008;53:68–80. [8] Schroder FH, Hugosson J, Roobol MJ, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012;366:981–90. [9] Jang TL, Yossepowitch O, Bianco Jr FJ, Scardino PT. Low risk prostate cancer in men under age 65: the case for definitive treatment. Urol Oncol 2007;25:510–4. [10] Pickles T, Ruether JD, Weir L, Carlson L, Jakulj F. Psychosocial barriers to active surveillance for the management of early prostate cancer and a strategy for increased acceptance. BJU Int 2007;100: 544–51. [11] Chamie K, Williams SB, Hu JC. Population-based assessment of determining treatments for prostate cancer. JAMA Oncol 2015;1: 60–7. [12] Chamie K, Williams SB, Hershman DL, Wright JD, Nguyen PL, Hu JC. Population-based assessment of determining predictors for quality of prostate cancer surveillance. Cancer 2015;121:4150–7. [13] Alibhai SM, Leach M, Warde P. Major 30-day complications after radical radiotherapy: a population-based analysis and comparison with surgery. Cancer 2009;115:293–302. [14] Wallis CJ, Mahar A, Cheung P, et al. New rates of interventions to manage complications of modern prostate cancer treatment in older men. Eur Urol 2016;69:933–41. [15] Hutchins VA, Samuels MB, Lively AM. Analyzing the affordable care act: essential health benefits and implications for oncology. J Oncol Pract 2013;9:73–7.
Please cite this article in press as: Williams SB, Chapin BF. Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom? Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.020
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom? Stephen B. Williams a, Brian F. Chapin b,* a
Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA; b Department of Urology, The University of Texas
MD Anderson Cancer Center, Houston, TX, USA
Preferred treatment options for localized prostate cancer include active surveillance for patients with low-risk disease, with surgery and radiation therapies reserved for intermediate-risk and high-risk disease [1,2]. Aside from tumor characteristics, determinants such as age, race/ ethnicity, socioeconomic status, and insurance have implications for the treatments administered [3–5]. In this issue of European Urology, Gray et al [6] present temporal trends in prostate cancer care using the National Cancer Database to identify trends in care and predictors of receipt of prostate cancer care. Specifically, the authors examined temporal effects of race/ethnicity, insurance, and socioeconomic status on treatment type during the study period. They differentiated observation versus treatment (radical prostatectomy [RP], brachytherapy, or external-beam radiotherapy) according to the National Comprehensive Cancer Network guideline on stratification for disease risk. While the authors should be commended for critically evaluating determinants for observation versus treatment according to disease risk, there are a few to discuss. First, the use of observation for clinically localized prostate cancer is not guideline-recommended for low-risk prostate cancer. In the present analysis, patients in the observation category probably include those who may be on watchful waiting or active surveillance. It should be cautioned that there remains a distinct difference between watchful waiting and active surveillance, since the latter entails detailed monitored follow-up, with treatment initiated at set determinants. Furthermore, active surveillance has been recommended for men diagnosed with low-risk prostate cancer [1,2]. However, the incidence of overtreatment of
low-risk disease is well known and still prevalent, as depicted in this study, with trends for greater RP utilization for low-risk disease [7,8]. In addition to determining predictors of increased utilization of active surveillance for indolent prostate cancer, the quality of surveillance has also been questioned [9,10]. Similar to the present study, previous research using SEER-Medicare linked data revealed significantly lower utilization of watchful waiting/active surveillance [11]. Moreover, in another study evaluating the quality of active surveillance, when comparing patients undergoing active treatment, those who underwent watchful waiting/active surveillance were less likely to undergo prostate-specific antigen testing and attend office visits within the 2 yr following diagnosis (p < 0.01) [12]. Of the 3656 patients undergoing watchful waiting/active surveillance, only 166 (4.5%) were on ‘‘active surveillance’’ (according to the a priori definition). This means that the current utilization of observation for lowrisk patients reported in the present study as 21.3% at best does not accurately represent active surveillance utilization patterns; it is likely that utilization is far less and underdetermined from the present data set. Interestingly, RP utilization increased independent of risk stratification, a surrogate for tumor biology. Furthermore, RP use increased in patients with high-risk disease during the study period, when historically radiation with androgen deprivation therapy was largely administered. With the introduction of robotic prostatectomy and further data supporting the utility of surgery as the initial step in therapy among patients with high-risk disease, these findings may not be surprising. However, even patients
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2016.08.047. * Corresponding author. Department of Urology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA. Tel. +1 713 7923250; Fax: +1 713 7944824. E-mail address: [email protected] (B.F. Chapin). http://dx.doi.org/10.1016/j.eururo.2016.10.020 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Williams SB, Chapin BF. Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom? Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.020
EURURO-7096; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
with higher comorbidity (Charlson comorbidity index 1 and 2) were more likely to undergo surgery than radiotherapy. Prior reports suggested that radiotherapy patients have greater comorbidity than surgery patients, with greater risk of perioperative complications and hospitalization [13,14]. Whether the increased trend for surgery among high-risk patients with greater comorbidity results in oncologic superiority with acceptable perioperative morbidity when compared to radiotherapy remains to be determined. Equally, with increasing understanding of the need for a multimodal approach to high-risk prostate cancer, whether surgery was the initial step (before adjuvant radiation and/or systemic therapy) and used to provide pathologic drivers for selecting appropriate secondary therapies is unclear, and may account for the increase in its utilization. Regardless of treatment, comorbidities and overall life expectancy should be taken into consideration when deciding on treatment and need to be discussed in the treatment decision-making process. Lastly, racial/ethnic disparities in prostate cancer care have previously been demonstrated. Moreover, the impact of insurance and socioeconomic status on cancer care represents hallmarks for improvement in current health care reform measures. The study findings have important implications for current decision-making aimed at improving health care through the Affordable Care Act (ACA) [15]. Over the next 10 yr, the ACA will bring in 37 million newly insured individuals, many of whom had limited access to insurance, cancer diagnosis, and treatment options, as well as those with more advanced cancer [15]. Moreover, the ACA provides significant consumer protections important to oncology patients, such as coverage of pre-existing conditions and mandated coinsurance limitations [15]. Leveling the access to care and minimizing the racial and socioeconomic disparities that exist will need to be a priority when evaluating the strategy of the ACA. In conclusion, the authors present a temporal trend for prostate cancer care in the USA that demonstrates greater utilization of RP across all risk categories, which needs to be interpreted in the context of the study design. Conflicts of interest: The authors have nothing to disclose.
References [1] Mohler JL, Armstrong AJ, Bahnson RR, et al. Prostate cancer, version 1.2016. J Natl Compr Cancer Netw 2016;14:19–30. [2] Heidenreich A, Bastian PJ, Bellmunt J, et al. EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent — update 2013. Eur Urol 2014;65:124–37. [3] Schmid M, Meyer CP, Reznor G, et al. Racial differences in the surgical care of Medicare beneficiaries with localized prostate cancer. JAMA Oncol 2016;2:85–93. [4] Wang EH, Yu JB, Abouassally R, et al. Disparities in treatment of patients with high-risk prostate cancer: results from a populationbased cohort. Urology 2016;95:88–94. [5] Williams SB, Prasad SM, Weinberg AC, et al. Trends in the care of radical prostatectomy in the United States from 2003 to 2006. BJU Int 2011;108:49–55. [6] Gray PJ, Lin CC, Cooperberg MR, Jemal A, Efstathiou JA. Temporal trends and the impact of race, insurance, and socioeconomic status in the management of localized prostate cancer. http://dx.doi.org/ 10.1016/j.eururo.2016.08.047. [7] Heidenreich A, Aus G, Bolla M, et al. EAU guidelines on prostate cancer. Eur Urol 2008;53:68–80. [8] Schroder FH, Hugosson J, Roobol MJ, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012;366:981–90. [9] Jang TL, Yossepowitch O, Bianco Jr FJ, Scardino PT. Low risk prostate cancer in men under age 65: the case for definitive treatment. Urol Oncol 2007;25:510–4. [10] Pickles T, Ruether JD, Weir L, Carlson L, Jakulj F. Psychosocial barriers to active surveillance for the management of early prostate cancer and a strategy for increased acceptance. BJU Int 2007;100: 544–51. [11] Chamie K, Williams SB, Hu JC. Population-based assessment of determining treatments for prostate cancer. JAMA Oncol 2015;1: 60–7. [12] Chamie K, Williams SB, Hershman DL, Wright JD, Nguyen PL, Hu JC. Population-based assessment of determining predictors for quality of prostate cancer surveillance. Cancer 2015;121:4150–7. [13] Alibhai SM, Leach M, Warde P. Major 30-day complications after radical radiotherapy: a population-based analysis and comparison with surgery. Cancer 2009;115:293–302. [14] Wallis CJ, Mahar A, Cheung P, et al. New rates of interventions to manage complications of modern prostate cancer treatment in older men. Eur Urol 2016;69:933–41. [15] Hutchins VA, Samuels MB, Lively AM. Analyzing the affordable care act: essential health benefits and implications for oncology. J Oncol Pract 2013;9:73–7.
Please cite this article in press as: Williams SB, Chapin BF. Patterns of Care for Prostate Cancer Patients: Predictors of Care, But For Whom? Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.020