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Substantial variation observed in treatment of localized prostate cancer
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There was substantial variation in the treatment of localized prostate cancer across 36 clinical sites, according to the results of a recently published study, indicating a need for high-quality comparative effectiveness research to help guide treatment decision-making.
According to researchers, there is insufficient evidence to conclude that there is greater benefit with any given treatment compared with another. Due to the lack of evidence, clinician and patient preferences and values play a significant role in determining treatment approaches, which in turn lead to unwarranted variation across health care regions.
To determine trends over time at varying levels of risk and to characterize and quantify variation at the level of clinical practice site, the researchers examined data from the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a disease registry of men with biopsy-proven prostate adenocarcinoma.
Of 11,892 men analyzed, 6.8% elected watchful waiting/active surveillance, 9.9% radical prostatectomy, 11.6% external beam radiation therapy, 13.3% brachytherapy, 4% cryoablation and 14.4% primary androgen deprivation monotherapy.
Men undergoing prostatectomy were younger than those undergoing other treatments, healthier, more likely to have private insurance and more likely to have high socioeconomic status. Patients undergoing brachytherapy and cryoablation were older and had lower socioeconomic status and higher comorbidity, followed by patients undergoing external beam radiation, primary androgen deprivation and watchful waiting (P<.001).
Proportions of prostatectomy, brachytherapy and watchful waiting decreased with increasing risk as measured by the Cancer of the Prostate Risk Assessment score; the proportion of primary androgen deprivation monotherapy increased.
There was substantial variation across practice sites. Watchful waiting ranged from 0% to 28%; prostatectomy ranged from 11% to 82%; brachytherapy ranged from 0% to 47%; external beam radiation ranged from 1% to 33%; cryoablation ranged from 0% to 40% and androgen deprivation ranged from 0% to 40%.
In multivariable analysis, the proportion of variation attributable to practice site ranged from 13% for androgren deprivation to 74% for cryoablation. Fourteen percent of variation was attributable to practice site for neoadjuvant androgen deprivation with external beam radiation.
“A growing body of evidence suggests that improved decision support may not only improve decision quality and reduce decisional regret but may also be a means to reduce unwarranted variation in health care,” the researchers wrote. “Incorporation of such decision support into clinical practice, while challenging, should be a priority.”
For more information:
- Cooperberg MR. J Clin Oncol. 2010;doi:10.1200/JCO.2009.26.0133.