Surgery rates for high-risk prostate cancer (PCa) doubled from 2004 to 2016 in the United States without guideline evidence suggesting its superiority over radiation therapy (RT), while use of RT has declined, according to new study findings.

High-risk disease accounted for 11.8% of PCa cases in 2004 and significantly increased to 20.4% of cases (P <.001) in 2016. Over the same period, the proportion of men with high-risk PCa undergoing radical prostatectomy (RP) significantly increased from 22.8% to 40.5% (P <.001). In contrast, RT rates significantly declined from 59.7% to 43.3% (P <.001).

The odds of undergoing RP significantly increased 2.3-fold from 2004 to 2013, then held steady through 2016 (P <.001), even among Black men, Himanshu Nagar, MD, of Weill Cornell Medicine in New York, New York, and colleagues reported in JAMA Network Open.

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Just 12.6% of patients with high-risk disease received external beam radiation therapy (EBRT) with a brachytherapy boost.

“The increasing use of robotic approaches suggests urologists and patients may regard prostatectomies safer than previous techniques,” Dr Nagar’s team explained. “Conversely, a decrease in radiotherapy may reflect reluctance toward recommended androgen deprivation therapy with radiotherapy . . . Trials are needed to guide optimal care.”

The likelihood of undergoing RP varied by geographic region. Compared with patients in New England (reference), those in the Mid-Atlantic, South Atlantic, Mountain, and Pacific, regions had approximately 1.4-, 1.1-, 2.0-, and 1.7-fold increased odds of undergoing RP, respectively (all P <.001). Patients in the East North, East South, West North, and West South parts of the Central region of the United States had approximately 1.4-, 2.5-, 2.2-, and 2.7-fold increased odds of undergoing RP, respectively (all P <.001).

Black men were 43% less likely than White men to undergo RP (P <.001), although the racial gap has narrowed somewhat over time. Socioeconomics and access to care partly explain the greater uptake of surgery. Greater RP use was associated with private insurance, longer travel distance to a medical facility, and less education. Greater use of robotic surgery correlated with higher income, private insurance, and treatment at an academic institution.

Patients with higher Gleason scores (especially 4+4 and higher), higher clinical stage, PSA greater than 4.0 ng/mL, or age older than 50 years were less likely to undergo RP.

 Using the National Cancer Database (NCDB), the investigators identified 214,972 men with high-risk PCa from 2004 to 2016, including 75,847 who underwent primary RP and 104,635 who underwent primary RT.  Men were classified as having high-risk disease if they had clinical stage T3-T4, PSA higher than 20 ng/mL, or a Gleason score of 8-10. White and Black men made up 79.2% and 16.1% of the cohort, respectively. Fifty-nine percent of patients had government-based insurance. Approximately 82% of the cohort had a Charlson-Deyo comorbidity index of 0.


Agrawal V, Ma X, Hu JC, et al. Trends in diagnosis and disparities in initial management of high-risk prostate cancer in the US. JAMA Netw Open. 2020;3(8):e2014674. doi:10.1001/jamanetworkopen.2020.14674

This article originally appeared on Renal and Urology News