Trends in Management for Patients With Localized Prostate Cancer, 1990-2013

Letters RESEARCH LETTER Trends in Management for Patients With Localized Prostate Cancer, 1990-2013 A growing literature supports the safety and efficacy of active surveillance for patients with low-risk prostate cancer. How- ever, the experience behind this literature is based almost en- tirely in academic centers, and prior reports have consis- tently found surveillance generally underused in most other settings. 1,2 Conversely, high-risk tumors have been under- treated with androgen deprivation treatment alone. 2,3 Re- cent trends in community-based practice patterns have not been well documented. Methods | Cancer of the Prostate Strategic Urologic Research En- deavor (CaPSURE) is a national registry accruing men with pros- tate cancer diagnosed at 45 urology practices across the United States since 1995. A mix of large and small practices are in- cluded. All but 3 are community-based practices and 28 states across all regions are represented. Both prospective enroll- ment of newly diagnosed men and retrospective enrollment of previously diagnosed men were permitted before 1998; how- ever, since 1998 all enrollment has been prospective. Approximately 90% of eligible patients are accrued. Urologists report clinical data; patients provide written consent under central institutional review board supervi- sion. Other methodological details have been reported. 4 We analyzed men with tumors classified as stage cT3aN0M0 or lower managed with prostatectomy, radiation, androgen deprivation monotherapy, or active surveillance/watchful waiting between 1990 and 2013. Only recently have these 2 terms been clearly separated, 1 and CaPSURE has histori- cally recorded them as a single category. There were 656 men (5.9%) with missing treatment data who were excluded. Cancer risk was stratified using the validated Cancer of the Prostate Risk Assessment (CAPRA) score. 5 We analyzed treatment trends over 5-year intervals in the full cohort and in a subset of men aged 75 years or older. We calculated Mantel-Haenszel tests for trends over time. There have been changes in the CaPSURE sites over time (eg, some have closed or withdrawn and others have been added). A subset analysis including only practices steadily contributing patients found substantially similar results. Analyses were performed with Stata version 12.1 (StataCorp). Statistical tests were 2-tailed with α = .05. Figure 1. Treatment Trends for the Overall Cohort in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) Registry Type of treatment Active surveillance/watchful waiting Radical prostatectomy CAPRA score range, 3-5 CAPRA score range, 6-10 Patients With Prostate Cancer, % Patients With Prostate Cancer, % Patients With Prostate Cancer, % CAPRA score range, 0-2 Year of Diagnosis Radiation therapy Primary androgen deprivation therapy Year of Diagnosis Year of Diagnosis Error bars indicate 95% confidence intervals; CAPRA, Cancer of the Prostate Risk Assessment. JAMA July 7, 2015 Volume 314, Number 1 (Reprinted) Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://jama.jamanetwork.com/ by a UCSF LIBRARY User on 07/28/2016 jama.com