While overtreatment of prostate cancer is a big concern in the United States, the other side of the Atlantic has the opposite problem — the latest data suggest that 4 in 10 men with locally advanced prostate cancer in England may be undertreated.
The latest figures show that 61% of men with locally advanced prostate cancer (LAPC) received radical treatment, such as radiotherapy or surgery along with hormonal treatment.
"Our work shows that up to 40% of patients diagnosed with high-risk or locally advanced prostate cancer may not be receiving the best available treatments in combination with hormonal therapy," commented lead author, Arun Sujenthiran, MBBS, MD, from the Royal College of Surgeons, England.
Mr Sujenthiran (surgeons in England are addressed as "Mr" or "Ms" rather than "Dr") presented the new findings here at the European Association of Urology (EAU) 2017 Congress.
Locally advanced prostate cancer is treated in several ways, and long-term studies have shown that radical treatments that aim to destroy all cancer tissues (and include radiotherapy and surgery) can improve survival compared with the use of hormonal treatment on its own, he explained. Hormonal treatment, such as androgen deprivation therapy, helps to slow the growth of the cancer but doesn't usually result in complete eradication of the prostate cancer, he added.
The new figures are the first to come from linking the recently established National Prostate Cancer Audit (NPCA) to other major UK databases, including the National Cancer Data Repository, the National Radiotherapy Dataset, and the Hospital Episodes Statistics database, and so give the most robust estimate of treatment rates, he commented
The study analyzed data come from the 2014–2015 records of the NPCA and include details on 11,957 men with LAPC. Of those who received radical therapy in addition to their hormone therapy,
The remainder of the group (39%) received hormonal treatment alone.
"We will follow the progress of these men to see if their survival has been affected as a result," Mr Sujenthiran commented.
These figures show an improvement on what was seen previously, he noted. The previous set of figures cover the period of 2010–2013 and show that during that period, only 47% of men received radical treatment for LAPC, so more than half (53%) were treated only with hormonal therapy.
In attempting to analyze why patients are not receiving radical treatment, he noted that age and comorbidities were risk factors for undertreatment. Patients older than age 75 years and those with two or more comorbidities were significantly less likely to receive radical treatment. So it may be that some of the men who were described as being "undertreated" may have been too frail or infirm to undergo surgery or radiotherapy.
Another factor was being diagnosed at a "nonhub" center. Mr Sujenthiran explained that in England, 48 centers have been designated as a central "hub" — hospitals with multidisciplinary teams that coordinate radical treatment pathways for all patients; however, an additional 100 nonhub centers also diagnose and refer patients to the hub hospitals.
Commenting on the new findings in a press statement, Mr Prasanna Sooriakumaran, urological consultant at University College London Hospital, said, "This study has demonstrated that in current practice many men do not have their high risk prostate cancer treated by radical surgery or radiotherapy and hormones. The true reasons for this are unexplained and need further investigation to ensure that all men with this type of prostate cancer receive maximal curative therapy when it is clinically appropriate."
Noel Clarke, NPCA urological clinical lead professor, said, "There is strong evidence that radiotherapy to the prostate combined with hormone therapy before and for a period after improves overall survival. The evidence for the use of surgery in this setting is less strong but some men are likely to benefit. We have limited evidence at present to show that surgery and hormone therapy is truly beneficial. Some healthy older men may be at risk of undertreatment. Further work is required to follow the long-term outcomes of these men but also to understand what factors contribute to some men in this cohort receiving radical treatment and others not."
Reacting to the findings at the meeting, chairman of the session, Brent Hollenbeck, MD, professor of urology at the University of Michigan, Ann Arbor, told Medscape Medical News that the rates of undertreatment of men with LAPC have decreased in recent years. "But the main issue is what is driving the residual undertreatment.... Is it patient preference, or is it a reluctance to treat because of competing risks of death, such as comorbidities?"
"Historically, the paradigm for LAPC has been to treat with androgen ablation and radiotherapy, but I do think think there is emerging data and consensus of expert opinion that surgery is a good option," he said. In particular, surgery can allow men to receive radiotherapy afterward, whereas it is diffuclt to have surgery after radiotherapy, and the consequences to quality of life are worse.
Dr Hollenbeck said that in the United States, rates of surgery for locally advanced prostate cancer are increasing, particlarly for younger men, and there is now a move toward surgery and local therapy for early metastatic disease.
At the meeting, a British surgeon in the audience wondered whether surgeons should argue their case more forcefully when potential treatments are being discussed at the mutidisciplinary team meetings, as he argued that prostatectomy and high-intensity focal ultrasound would be beneficial in some of these cases.
Commenting on the situation in the United States, Dr Hollenbeck said that undertreatment is not an issue because "the vast majority of men with locally advanced prostate cancer will have radical treatment." But that opens up a different question of whether this is overtreatment — some of these cancers may be biologically indolent and low risk and may not require any treatment.
There has been interest in the idea of following such low-risk prostate cancer with active surveillance, and this is happening in "some areas," he said, "but there are data to show that the majority of men with low-risk prostate cancer are treated in the US...and the initial reaction of many men is to have treatment." So some of it comes down to patient choice, but other factors in the United States come into play, including the fee-for-service insurance schemes that provide incentives to clinicians for treatment.
This research forms part of the work currently carried out by the NPCA, which is commissioned by the Health Quality Care Improvement Partnership as part of the National Clinical Audit Programme. Mr Sujenthiran has disclosed no relevant financial relationships.
European Association of Urology (EAU) 2017 Congress. Abstract 768. Presented March 26, 2017.
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