Reflecting changes from the US Preventive Services Task Force guidelines, which now recommend against routine prostate cancer screening, the overall rate of men receiving treatment for prostate cancer has declined by 42%, according to research published in Health Affairs. Among men who have been diagnosed, however, only 8% less are undergoing initial surgery or radiation treatments, despite evidence that surveillance may be an appropriate option.
“It’s not entirely surprising: Primary care doctors who perform the majority of screening were the target audience of US Preventive Services Task Force guidelines recommending against screening. But the specialists who treat prostate cancer once it’s diagnosed had a more tempered response,” said study author Tudor Borza, MD, MS, a urologic oncology and health services research fellow at Michigan Medicine.
Dr. Borza and fellow researchers identified 67,023 men with newly diagnosed prostate cancer between 2007 and 2012 using Medicare claims data, of whom almost 75% had initial curative treatment including surgery or radiation.
When they compared overall treatment rates from 2007 through 2012, these researchers observed a sharp decline of 42%, which may be reflective of the changes in screening recommendations and the adoption of surveillance strategies in select men made in 2008 by the US Preventive Services Task Force (USPSTF). The USPSTF guidelines then advised against routine screening in men older than 75 years. Additionally, in 2011, there was a recommendation made against all PSA screening, although societies such as the American Urological Association still advocate screening in men most likely to benefit.
“These findings suggest that primary care doctors significantly decreased the number of patients to whom they recommended PSA screening after the guidelines changed,” said Dr. Borza. “Primary care doctors make recommendations for screening to men who do not have cancer. They see men who have been treated for prostate cancer and have long-term effects such as incontinence or impotence. That favors a less-aggressive approach to the disease.”
Mirroring these less aggressive screening guidelines, attitudes toward treatment also became less aggressive. According to research, however, these responses were more tempered as treatment rates over time in men diagnosed with prostate cancer were examined.
The risk of treatment may outweigh the benefit, since prostate cancers are so slow-growing, according to data. Options include watchful waiting or active surveillance, particularly in patients with low-risk disease or a limited life expectancy. Through monitoring, urologists can identify when treatment may be necessary.
Despite these paradigm shifts, however, treatment rates did not change quickly, with only 8% fewer patients who were diagnosed with prostate cancer receiving treatment from 2007 through 2012.
“Specialists understand how insidious prostate cancer can be,” noted Dr. Borza. “They recognize the problems arising from over-diagnosis and overtreatment, but they also see people suffering from painful metastases or dying from the disease. When you’re exposed to that, you’re likely going to have a more reserved approach towards surveillance strategies,” he added.
In particular, they paid attention to patients who had a high risk of dying within 10 years from causes other than prostate cancer, including old age and heart disease.
“If we had expected a big change in treatment for observation, it would have been in this group,” said Dr. Borza. “These are the men for whom most physicians agree the risks of treatment outweigh the benefits. But there was no change in their treatment rate, meaning that adoption of less aggressive treatment strategies is occurring more slowly than the decrease in PSA screening.”
They emphasized the value of care over volume in future payment models and policies as incentives for specialists to choose observation rather than treatment, and urged participation in quality improvement initiatives, like the Michigan Urological Surgery Improvement Collaborative.
Identifying men at the highest risk of aggressive prostate cancer who could most benefit from screening and treatment is of paramount importance, added Dr. Borza.
“That’s really the concern here. We know prostate cancer is a deadly disease in some men. We need better tools to identify which men should be screened and among those diagnosed, which men should be treated aggressively. This is still a black box. It’s that uncertainty that leads to different approaches to treatment based on how different physicians view the risk. If we get better at predicting who’s at highest risk, we can more accurately tailor screening and treatment,” he concluded.
This study was funded by National Cancer Institute grants R01 CA168691, R01 CA174768, T32 CA180984.