Prostate cancer treatment mismatched with clinical benefit

Over the past decade, prostate cancer treatment has become increasingly aggressive for men with a low likelihood of clinical benefit, with no commensurate increase in the treatment of men with a high likelihood of clinical benefit.

Investigators evaluated Medicare data for 39,270 men, aged 67 to 84 years (median age 74 years), who had been diagnosed with localized prostate cancer between 1998 and 2007. Overall, the use of curative therapy (radical prostatectomy or radiation therapy, as opposed to active surveillance) rose from 61.2% to 67.6% during the period studied. Approximately 39.1% of 3,557 patients with a short life expectancy (less than 5 years), 62.7% of 23,721 patients with an intermediate life expectancy (5 to 10 years), and 75.1% of 11,992 patients with a long life expectancy (10 years or more) received curative therapy.

The analysis uncovered a trend toward higher use of curative treatment for prostate cancer among men with moderate-risk prostate cancer and a short life expectancy, rising from 38.0% in 1998-1999 to 52.1% in 2006-2007. However, the use of curative therapy fell from 80.7% to 80.0% among men with moderate-risk tumors and a long life expectancy.

In the group with low-risk tumors, the use of curative therapy trended downward for men with a long life expectancy, but increased for men with a short or intermediate life expectancy.

“While not treating potentially fatal cancer can reflect poor-quality care, aggressive management of disease that is unlikely to progress puts patients at risk for morbidity and increases cost without medical benefits,” pointed out the investigators in their research letter for Archives of Internal Medicine (2012;172[4]:362-263). “Given widespread concerns about the rate of increase in Medicare expenditures, it is notable that the most substantial increase in treatment in our sample was noted among patients who were least likely to benefit.”

The authors cited financial incentives, emergence of new therapies with perceived lower adverse-effect profiles, and changes in patient preferences as possible explanations for these treatment patterns.

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