Schymura et al. BMC Cancer 2010, 10:152 http://www.biomedcentral.com/1471-2407/10/152 Institute of Medicine reports suggesting that central can- cer registries be utilized for tracking cancer treatment [1,2] the Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries (NPCR) undertook a multi-state Patterns of Care study to identify cancer treatment in a cross-section of the United States. In order to include follow-up data for survival analysis in the project, the study design was retrospective, based on cancers diagnosed in 1997. According to the National Cancer Institute's (NCI's) Physician Data Query from 1996, acceptable treatment options for localized prostate cancer included surgical removal of all of the prostate and some surrounding tis- sue (radical prostatectomy); radiation therapy, either external beam or interstitial (brachytherapy); and careful observation without further immediate treatment ("watchful waiting"). Hormone therapy, another option, could be achieved by either orchiectomy (surgical removal of the testicles) or the administration of drugs to block hormone production or action [3]. These recom- mendations have not changed substantially in the inter- vening years [4]. According to the current Clinical Practice Guidelines of the National Comprehensive Can- cer Network [5], observation, radiation, and radical pros- tatectomy are all reasonable treatment options for localized prostate cancer, the treatment decision being based on balancing expected long-term survival in the absence of treatment against individual tolerance for the side effects of current therapies. Objectives The objectives of the current study were to describe the initial treatment patterns for localized prostate cancer in a population-based sample and to determine the clinical and patient characteristics associated with initial treat- ment. In particular, what factors are related to choice of conservative management versus definitive treatment; and among patients receiving definitive treatment, what factors are related to radiation therapy versus radical prostatectomy? Radical prostatectomy and radiation therapy are viewed as definitive treatment for localized prostate cancer; that is, they are potentially curative because they remove or destroy cancerous tissue. Hor- mone therapy and watchful waiting are considered non- curative and are classified as conservative management. A secondary objective of the current study was to deter- mine whether mode of initial treatment for localized prostate cancer was related to patient survival. Methods The CDC-NPCR Breast, Colon, and Prostate Cancer Data Quality and Patterns of Care Study (PoC1) involved seven participating states (California, Colorado, Illinois, Louisiana, New York, Rhode Island, and South Carolina) Page 2 of 15 and the CDC. The sampling methodology for this study has been explained in detail elsewhere [6,7]. In brief, ran- dom samples of cancer patients diagnosed in 1997 were selected from the databases of the participating central cancer registries. Institutional Review Board approval for use of the data was obtained at every participating uni- versity or health department and at the Centers for Dis- ease Control and Prevention. Inclusion Criteria Patients included in the current analysis were those diag- nosed in 1997 with a first primary prostate cancer (ICD- O-2: C61.9; Behavior = 3; sequence number 00 or 01), diagnosed at a clinically localized stage. Since the deter- mination of pathologic staging requires histologic exami- nation of the resected specimen, usually involving total prostatoseminalvesiculectomy and pelvic lymph node dissection [8], pathologic staging would only be available for patients who had undergone radical prostatectomy. Patients were considered to have clinically localized dis- ease if (1) the tumor was clinically inapparent (i.e., not palpable or visible by imaging) or (2) the tumor was con- fined within the prostate (cT1c and cT2), and there was no clinical evidence of nodal involvement and no evi- dence of metastasis. Frequently, when pathologic staging information was available in the medical record, clinical staging information was not documented. Therefore, patients with pathologic assessment of the tumor (pT1 and pT2) were also included as long as there was no clini- cal evidence of nodal involvement and no evidence of metastasis. Additionally, only patients with microscopi- cally confirmed adenocarcinomas who were alive six months post diagnosis were included in the analysis. Measurement Hospital medical records of the study cases were reab- stracted by specially trained staff in each state, using a common data entry form. Demographic, diagnostic, stag- ing, and treatment data were obtained for each patient from hospital charts, supplemented by records from phy- sicians' offices and from ambulatory surgery and radia- tion therapy facilities. Because the proportion of Hispanics residing in many parts of the study area was low, Hispanic ethnicity was frequently not noted in the medical record (e.g., the hospital intake form did not include an ethnicity check-off ). Patients were categorized as non-Hispanic unless there was evidence to the con- trary (e.g., reference to Hispanic ethnicity in the history and physical section of the medical record). Race and eth- nicity information was combined to create four groups: Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic other (including Asian/Pacific Islander). ICD-9-CM codes that were recorded in medical records were abstracted to assess the presence of comorbid ill-