More men with low-risk prostate are undergoing advanced treatment, including robotic prostatectomies and intensity-modulated radiotherapy, even though their risk of non-cancer mortality is much higher, researchers from University of Michigan, Ann Arbor, reported in JAMA (June 26th 2013 issue).

The authors added that these low-risk prostate cancer patients will likely not benefit from advanced treatment technologies.

Several studies have shown that “watchful waiting” does not result in higher mortality among older men with low-risk prostate cancer. An article published in Annals of Internal Medicine earlier this month showed that observation is better and cheaper for prostate cancer patients with low-risk, localized disease than undergoing immediate treatment.

The authors of the JAMA article wrote as background information:

“Prostate cancer is a common and expensive disease in the United States. In part because of the untoward morbidity of traditional radiation and surgical therapies, advances in the treatment of localized disease have evolved over the last decade. Chief among these are the development of intensity-modulated radiotherapy (IMRT) and robotic prostatectomy. During a period of increasing population-based rates of prostate cancer treatment, both of these advanced treatment technologies have disseminated rapidly.

However, the rapid growth of IMRT and robotic prostatectomy may have occurred among men with a low risk of dying from prostate cancer. Recognizing the protracted clinical course for most of these cancers, clinical guidelines recommend local treatment only for men with at least a 10-year life expectancy.”

The researchers suggest that aggressive marketing aimed directly at the consumer, plus incentives linked with fee-for-service payment may have encouraged the use of advanced treatment technologies. “The extent to which these advanced treatment technologies have disseminated among patients at low risk of dying from prostate cancer is uncertain,” they added.

There is growing concern about the overtreatment of men with low-risk, localized prostate cancer. Understanding the patterns of new technology use among these patients is especially important.

Bruce L. Jacobs, M.D., M.P.H., and team set out to determine the extent of advanced treatment technology usage among patients considered to be at low risk of dying from prostate cancer, compared to traditional treatments used before, such as open radical prostatectomy and EBRT (external beam radiation treatment).

The team used SEER-Medicare data (SEER = Surveillance, Epidemiology, and End Results) and identified a group of males who had been diagnosed with prostate cancer between 2004 and 2009:
  • 23,633 underwent IMRT
  • 3,926 underwent EBRT
  • 16,384 underwent “watchful waiting” (observation)
They also examined follow-up data up to the end of 2010. Low-risk prostate cancer included patients with clinical stage ≤T2a, biopsy Gleason score ≤6, and PSA (prostate-specific antigen) level ≤10 ng/mL. High-risk of non-cancer mortality was defined as the likelihood of that patient dying within ten years if he had not had a cancer diagnosis, i.e. if the patient dies prematurely, it probably won’t be the prostate cancer that kills him.

The investigators reported that the use of advanced treatment technologies among men diagnosed with prostate cancer:
  • Increased among patients with low-risk disease, from 32% in 2004 to 44% in 2009

  • Increased among patients with high risk of non-cancer mortality, from 36% in 2004 to 57% in 2009

  • Rose among patients with both low risk prostate cancer and a high risk of non-cancer mortality, from 25% in 2004 to 34% in 2009
Of all the men in SEER who had been diagnosed with prostate cancer, the use of advanced technologies for those unlikely to die from the disease rose to 24% in 2009 from 12% in 2004, an 85% relative increase.

The researchers wrote:

“That is, rates of IMRT and robotic prostatectomy use increased from 129.2 per 1,000 patients in 2004 to 244.2 per 1,000 patients diagnosed with prostate cancer in 2009. At the same time, the use of prior standard treatments for men least likely to benefit decreased from 11 percent in 2004 to 3 percent in 2009.

The increasing use of both IMRT and robotic prostatectomy in populations unlikely to benefit from treatment was largely explained by their substitution for the treatments they aim to replace, namely EBRT and open radical prostatectomy.”



The authors believe that the absolute magnitude of the usage of high-end treatment technologies in populations with low-risk prostate cancer has two important implications:
  • Both treatments – robotic prostatectomy and intensity-modulated radiotherapy – are more costly than previous standards, with start-up costs close to $2 million. IMRT is also associated with higher total episode payments, which add another $1.4 billion to annual spending. “Thus, the implications of any potential overtreatment with these advanced treatment technologies are amplified in financial terms.”

  • These high-end technologies were implemented in populations unlikely to benefit from treatment during a period of growing awareness about the very slow progression of many prostate cancers, as well as more and more calls for holding back on immediate treatment for these patients. “Our findings suggest that even during this period of enhanced stewardship, incentives favoring the diffusion of these technologies outweighed those related to implementing a more conservative management strategy.”
The researchers concluded:

“Continued efforts to differentiate indolent from aggressive disease and to improve the prediction of patient life expectancy may help reduce the use of advanced treatment technologies in this patient population.”

The USPSTF (US Preventive Services Task Force) wrote in Annals of Internal Medicine that the harms of PSA-based testing for prostate cancer outweigh the benefits. The authors wrote “(PSA-testing) may benefit a small number of men but will result in harm to many others”.

Written by Christian Nordqvist