Utilization and expense of adjuvant cancer therapies following radical prostatectomy

Radical prostatectomy is the most common treatment choice among men newly diagnosed with prostate cancer. Cure from prostate cancer, as evidenced by an undetectable prostate-specific antigen (PSA) following surgery, is highly dependent upon the tumor being localized to the prostate gland and removed in total by the urologic surgeon. The strongest predictors of organ-confined disease are the prostate cancer triumvirate of preoperative PSA, clinical stage, and tumor grade from the diagnostic prostate biopsy expressed in the Gleason grading system (usually on a scale from 6 to 10). Cancers that have a Gleason score from 8 to 10 are pathological stage T3 or are present on the surgical margin or in pelvic lymph nodes are considered at highest risk of recurring, as evidenced by a detectable PSA. Patients who exhibit these adverse features at surgery are candidates to undergo adjuvant therapies such as radiation therapy and androgen deprivation therapy. In this issue of Cancer, Hu and colleagues describe the utilization of adjuvant therapies among elderly prostate cancer patients with advanced pathological features at surgery. Using the SEER-Medicare–linked database, an excellent resource for describing patterns of care in this disease setting, the authors focus on patients with high-risk preoperative cancer features and surgeon volume as predictors of undergoing adjuvant therapy and the resulting health care expenditures. Physicians who treat prostate cancer face the difficult challenge of avoiding overtreatment and its corresponding costs, including functional, financial, and quality-of-life costs. Most attention has focused on curbing overtreatment in the setting of primary therapy for early-stage prostate cancer. More recently, several studies have investigated costs incurred in the adjuvant and salvage settings. The accepted solution to overtreatment for primary treatment has been the application of various risk stratification tools to determine who best to treat. However, evaluations of national practice patterns suggest that a risk-stratified approach is not taken with initial therapies, particularly in the elderly. Furthermore, the burden of treatment costs is heavily weighted toward the end of life in prostate cancer. Even during the first year of treatment following diagnosis, only 25% of net costs are from hospitalizations. As many as one-third of all men undergoing radical prostatectomy demonstrate high-risk pathological features and are candidates for adjuvant therapy. Thus, the study by Hu and colleagues represents an appropriate next step in comparing the effectiveness and costs of prostate cancer therapies. A 2007 American Urological Association guideline recommends that adjuvant radiation and/or hormonal therapy be given to men with adverse pathological features found at radical prostatectomy. Three randomized trials investigating adjuvant radiation for patients with advanced pathological features at radical prostatectomy have shown decreased rates of biochemical failure, and a 2009 update of SWOG S8794 showed improved survival. With this guideline and these trial findings, the use of adjuvant radiation in the management of advanced disease has become more appropriate, but whether it has become the standard of care remains unanswered. Although the time frame for this study predates the guideline, the findings suggest that the uptake of adjuvant therapy has been slow in the community. Specifically, patients receiving adjuvant therapy included only 32% of those with a positive surgical margin, 36% of those with pathological stage T3a cancer, and 76% of those with positive lymph nodes. In fact, overall use decreased during the 3 years of the study from 15% in 2004 to 10% in 2006. Although adverse cancer features, an appropriate determinant of undergoing adjuvant therapy, were strongly predictive of adjuvant treatment, it is disappointing to see that neither older age nor the presence of more comorbidities