Determining cause of death in prostate cancer: are death certificates valid?

The impact of PSA screening on prostate cancer mortality and overdiagnosis of prostate cancer in the United States

BACKGROUND

The study assessed the impact of prostate-specific antigen (PSA) testing in the United States by comparing the rates of PSA testing in U.S. counties to the rates of prostate biopsies and newly treated prostate cancer and to deaths from prostate cancer.

METHODS

We examined the association between the percentage of men aged 66-74 from a nationally representative 5% Medicare sample who received PSA testing in each U.S. county in 1997 and the percent of men who received prostate biopsies or treatment for newly diagnosed prostate cancer in 1997 as well as mortality from prostate cancer and from all other causes from 1998 to 2007.

RESULTS

Analyses of 1,067 U.S. counties showed a significant relationship between the rate of PSA testing and both the rate of men undergoing treatment for prostate cancer and prostate cancer mortality (both p < .001) but no relationship with mortality from other causes. For every 100,000 men receiving a PSA test in 1997, an additional 4,894 men underwent prostate biopsy and 1,597 additional men underwent prostate cancer treatment in 1997, and 61 fewer men died from prostate cancer during 1998-2006. Analyses stratified by age and race produced similar results.

CONCLUSIONS

PSA testing was associated with modest reductions in prostate cancer mortality and large increases in the number of men overdiagnosed with and overtreated for prostate cancer. The results are similar to those obtained by the large European randomized prospective trial of PSA testing.

Explaining racial differences in prostate cancer mortality

BACKGROUND

In the United States, black males have an annual death rate from prostate cancer that is 2.4 times that of white males. The reasons for this are poorly understood.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare database, 77,038 black and white males aged >65 years were identified with a first primary diagnosis of prostate cancer between 1995 and 2005, as well as 49,769 controls. The racial gap in mortality was decomposed to differential incidence and stage-specific prostate cancer mortality. The importance of various clinical and socioeconomic factors to each of these components was then examined.

RESULTS

The estimated mortality gap for prostate cancer-specific mortality was 1320 more cases per 100,000 males among black than white men. This gap was due to higher prostate cancer incidence among black males (76%) and higher stage-specific mortality once diagnosed (24%). Differences in prostate-specific antigen testing, comorbidities, and income explained 29% of the difference in metastatic cancer incidence but none of the racial gap for local/regional incidence. Conditional on diagnosis, tumor characteristics explained 50% of the racial gap, comorbidities an additional 4%, choice of treatment and physician 17%, and socioeconomic factors 15%. Overall, approximately 25% of the racial gap in mortality and 86% of the gap in mortality conditional on diagnosis could be explained.

CONCLUSIONS

More frequent prostate-specific antigen testing for black and low-income males could potentially reduce the prostate cancer mortality gap through earlier diagnosis of tumors that otherwise may become metastatic. More aggressive treatment of prostate cancer, especially in poor communities, might also reduce the gap.

A non-cancer-related survival benefit is associated with partial nephrectomy

BACKGROUND

Partial nephrectomy (PN) may better protect against other-cause mortality (OCM) when compared with radical nephrectomy (RN) in patients with localized renal cell carcinoma (RCC).

OBJECTIVE

Test the effect of treatment type on OCM.

DESIGN, SETTING, AND PARTICIPANTS

Using the Surveillance Epidemiology and End Results-Medicare-linked database, 4956 RN patients (82%) and 1068 PN patients (18%) with T1a RCC were identified (1988-2005).

MEASUREMENTS

To adjust for inherent differences between treatment types, we relied on propensity-matched analyses. One-to-one matching was performed according to age, sex, race, baseline Charlson comorbidity index (CCI), baseline diagnosis of hypercalcemia and hyperlipidemia, socioeconomic status (SES), population density, tumor size, and year of surgery. The 2- and 5-yr OCM rates were computed using cumulative incidence. Univariable and multivariable competing-risks regression analyses for prediction of OCM were performed according to treatment type. Adjustment was made for cancer-specific mortality (CSM), patient age, CCI, sex, race, SES, tumor grade, and year of surgery.

RESULTS AND LIMITATIONS

Following propensity-based matching, 1068 RN patients were matched with 1068 PN patients. The 2- and 5-yr OCM rates after nephrectomy were 5.0% and 16.0% for PN versus 6.9% and 18.1% for RN, respectively. In the postpropensity multivariable analyses, patients who underwent PN were significantly less likely to die of OCM compared with their RN-treated counterparts (hazard ratio [HR]: 0.83; 95% confidence interval, 0.69-0.98; p=0.04). Increasing age (HR: 1.08, p<0.001), higher CCI (HR: 1.14, p<0.001), female gender (HR: 0.79, p=0.02), baseline hypercalcemia (HR: 2.05, p=0.03), baseline hyperlipidemia (HR: 0.73, p=0.003), and year of surgery (HR: 0.95, p=0.003) were independent predictors of OCM.

CONCLUSIONS

Compared with PN-treated patients, RN-treated patients are more likely to die of OCM after surgery, even after adjusting for CSM, as well as baseline CCI. Consequently, PN should be offered whenever technically feasible.

Cause-specific mortality following radical prostatectomy

BACKGROUND

To evaluate cause-specific mortality following radical prostatectomy (RP) in a population cohort of US men adjusting for competing risks.

METHODS

The Surveillance, Epidemiology and End Results (SEER) database was used to identify 120,392 men undergoing RP for clinically localized prostate cancer between 1988 and 2003. Cause-specific mortality data were extracted through 2006 and cumulative incidence was estimated using a competing risks approach.

RESULTS

The stage distribution of the cancers was 32% local, 28% regional, 40% unknown, and 80% of tumors Gleason ≤ 7. Median follow-up was 7 years. The 15-year prostate cancer-specific mortality was 5.3% and the non-prostate cancer mortality was 30.6%. Stage, grade and race had minimal impact on non-prostate cancer mortality. At 15 years following surgery, mortality due to cardiovascular diseases was 11%, other cancers 9.1%, and other causes 10.5%. Among men ≥ 65 years, 15-year cancer-specific mortality was 6% and non-prostate cancer mortality was 40.8%.

CONCLUSIONS

Following RP, death from cardiovascular diseases, other cancers, and other causes is far more common than death from prostate cancer. In men diagnosed with prostate cancer, significant efforts should be made to prevent, diagnose, and treat these diseases.

Use of restaging bladder tumor resection for bladder cancer among Medicare beneficiaries

OBJECTIVE

To evaluate the use and effectiveness of restaging bladder tumor resection using population-based data. Restaging bladder tumor resection improves staging accuracy and the response to intravesical therapy. However, its use outside of a tertiary care setting, and its subsequent clinical implications, are unknown.

METHODS

We identified 62 016 patients diagnosed with bladder cancer between 1992 and 2005 using SEER-Medicare data. Restaging bladder tumor resection was defined as 2 or more resections occurring within 60 days of diagnosis. Using multivariable models, we assessed the relationship between the use of restaging resection and cancer-specific survival.

RESULTS

Restaging resection was performed in only 3064 (4.9%) of newly diagnosed bladder cancer patients, but was most common among those with high grade (7.7% vs 2.0% in low grade, P < .001) and stage (8.8% in T2 vs 2.8% in Ta/Tis, P < .001) disease. Compared to patients with muscle-invasive cancers who did not undergo restaging at diagnosis, restaging resection was associated with improved 5-year cancer-specific mortality among pathologically staged patients (20.4% vs 28.0%, P = .02), while clinically staged patients trended toward improved mortality (28.2% vs 31.9%, P = .07).

CONCLUSION

Restaging transurethral resection for bladder cancer is relatively uncommon and associated with improved survival among patients with muscle invasive bladder cancer. Greater use of restaging warrants further investigation as a simple means of improving outcomes among patients suspected of having muscle invasive disease.

Cancer-specific and other-cause mortality after radical prostatectomy versus observation in patients with prostate cancer: competing-risks analysis of a large North American population-based cohort

BACKGROUND

Initial treatment options for low-risk clinically localized prostate cancer (PCa) include radical prostatectomy (RP) or observation.

OBJECTIVE

To examine cancer-specific mortality (CSM) after accounting for other-cause mortality (OCM) in PCa patients treated with either RP or observation.

DESIGN, SETTING, AND PARTICIPANTS

Using the Surveillance Epidemiology and End Results Medicare-linked database, a total of 44 694 patients ≥65 yr with localized (T1/2) PCa were identified (1992-2005).

INTERVENTION

RP and observation.

MEASUREMENTS

Propensity-score matching was used to adjust for potential selection biases associated with treatment type. The matched cohort was randomly divided into the development and validation sets. Competing-risks regression models were fitted and a competing-risks nomogram was developed and externally validated.

RESULTS AND LIMITATIONS

Overall, 22,244 (49.8%) patients were treated with RP versus 22450 (50.2%) with observation. Propensity score-matched analyses derived 11,669 matched pairs. In the development cohort, the 10-yr CSM rate was 2.8% (2.3-3.5%) for RP versus 5.8% (5.0-6.6%) for observation (absolute risk reduction: 3.0%; relative risk reduction: 0.5%; p<0.001). In multivariable analyses, the CSM hazard ratio for RP was 0.48 (0.38-0.59) relative to observation (p<0.001). The competing-risks nomogram discrimination was 73% and 69% for prediction of CSM and OCM, respectively, in external validation. The nature of observational data may have introduced a selection bias.

CONCLUSIONS

On average RP reduces the risk of CSM by half in patients aged ≥65 yr, relative to observation. The individualized protective effect of RP relative to observation may be quantified with our nomogram.

Disease-specific mortality may underestimate the total effect of prostate cancer screening

OBJECTIVES

To study the difference between the disease-specific and excess mortality rate in the European Randomized Study of Screening for Prostate Cancer section Rotterdam.

METHODS

A total of 42,376 men were randomized to systematic screening or usual care. The excess number of deaths was defined as the difference between the observed number of deaths in the prostate cancer (PC) patients and the expected number of deaths up to 31 December 2006. The expected number was derived from mortality of all study participants before a possible diagnosis with PC. The disease-specific mortality rate was based on the number of men who died from PC. The excess mortality rate based on the arm-specific excess number of deaths and the disease-specific mortality rate were compared between the two study arms.

RESULTS

The overall mortality rate was not significantly different between the intervention and the control arms of the study: RR 1.02 (95% CI 0.98-1.07). The disease-specific mortality rate was 0.42 men per 1000 person-years in the intervention and 0.48 men per 1000 person-years in the control arm: RR 0.86 (95% CI 0.64-1.17). The excess mortality rate was 0.40 per 1000 person-years in the intervention arm and 0.61 men per 1000 person-years in the control arm, and the RR for excess mortality was 0.66 (95% CI 0.39-1.13).

CONCLUSIONS

In contrast to the disease-specific mortality rates an increased difference in the excess mortality rates was observed between the two arms. This observation may be due to a systematic underestimation of the disease-specific deaths, and/or an additional disease-related mortality that is measured by an excess mortality analysis but not by a disease-specific mortality.

Standard outcome measures for thymic malignancies

Thymic malignancies present particular issues due to the pace of disease progression, patterns of recurrence, and causes of death that make nuances of how outcomes are reported particularly important. The relatively limited number of patients also creates a challenge to glean as much as possible from the available experience, but risks over-interpretation and potentially misleading conclusions. Therefore the International Thymic Malignancy Interest Group has developed a set of standards for reporting of outcome measures of clinical studies, which have been adopted for collaborative projects undertaken by the organization. Widespread adoption of this baseline will enhance the ability to compare results from different series.

Impact of comorbidity on survival among men with localized prostate cancer

PURPOSE

To provide patients and clinicians more accurate estimates of comorbidity-specific survival stratified by patient age, tumor stage, and tumor grade.

PATIENTS AND METHODS

We conducted a 10-year competing risk analysis of 19,639 men 66 years of age and older identified by the Surveillance, Epidemiology, and End Results (SEER) program linked to Medicare program files. All men were diagnosed with localized prostate cancer and received no surgery or radiation within 180 days of diagnosis. The analysis was stratified by tumor grade and stage and by age and comorbidity at diagnosis classified using the Charlson comorbidity index. Underlying causes of death were obtained from SEER.

RESULTS

During the first 10 years after diagnosis, men with moderately and poorly differentiated prostate cancer were more likely to die from causes other than their disease. Depending on patient age, Gleason score, and number of comorbidities present at diagnosis, 5-year overall mortality rates for men with stage T1c disease ranged from 11.7% (95% CI, 10.2% to 13.1%) to 65.7% (95% CI, 55.9% to 70.1%), and prostate cancer-specific mortality rates ranged from 1.1% (95% CI, 0.0% to 2.7%) to 16.3% (95% CI, 13.8% to 19.4%). Ten-year overall mortality rates ranged from 28.8% (95% CI, 25.3% to 32.6%) to 94.3% (95% CI, 87.4% to 100%), and prostate cancer-specific mortality rates ranged from 2.0% (95% CI, 0.0% to 5.3%) to 27.5% (95% CI, 21.5% to 36.5%).

CONCLUSION

Patients and clinicians should consider using comorbidity-specific data to estimate the threat posed by newly diagnosed localized prostate cancer and the threat posed by competing medical hazards.

Delays in diagnosis and bladder cancer mortality

BACKGROUND

Mortality from invasive bladder cancer is common, even with high-quality care. Thus, the best opportunities to improve outcomes may precede the diagnosis. Although screening currently is not recommended, better medical care of patients who are at risk (ie, those with hematuria) has the potential to improve outcomes.

METHODS

The authors used the Surveillance, Epidemiology, and End Results-Medicare linked database for the years 1992 through 2002 to identify 29,740 patients who had hematuria in the year before a bladder cancer diagnosis and grouped them according to the interval between their first claim for hematuria and their bladder cancer diagnosis. Cox proportional hazards models were fitted to assess relations between these intervals and bladder cancer mortality, adjusting first for patient demographics and then for disease severity. Adjusted logistic models were used to estimate the patient's probability of receiving a major intervention.

RESULTS

Patients (n = 2084) who had a delay of 9 months were more likely to die from bladder cancer compared with patients who were diagnosed within 3 months (adjusted hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.20-1.50). This risk was not markedly attenuated after adjusting for disease stage and tumor grade (adjusted HR, 1.29; 95% CI, 1.14-1.45). In fact, the effect was strongest among patients who had low-grade tumors (adjusted HR, 2.11; 95% CI, 1.69-2.64) and low-stage disease (ie, a tumor [T] classification of Ta or tumor in situ; adjusted HR, 2.02; 95% CI, 1.54-2.64).

CONCLUSIONS

A delay in the diagnosis of bladder cancer increased the risk of death from disease independent of tumor grade and or disease stage. Understanding the mechanisms that underlie these delays may improve outcomes among patients with bladder cancer.

Therapeutic value of lymph node dissection at radical prostatectomy: a population-based case-cohort study

OBJECTIVE

• To examine the association between the number of lymph nodes removed in pelvic lymphadenectomy and the risk of prostate cancer death, particularly in low to intermediate risk prostate cancer patients.

PATIENTS AND METHODS

• Data on a subset of patients from a population-based case-cohort study was used to assess the effect of lymph node removal on prostate cancer-specific mortality. • The subset included in this report were those 281 patients from the parent study who were treated with prostatectomy and had a pelvic lymph node dissection and for whom we had a record of the number of nodes removed (the sub-cohort) and 41 patients fitting the same criteria who died of their prostate cancer within 10 years (the cases). • Study variables included number of lymph nodes removed, lymph node status, age, pre-treatment PSA, T category, Gleason score and use of hormonal therapy. • We ran a Cox proportional hazards regression analysis that accounted for the study design and allowed us to consider these patient and disease characteristics as potential confounders of the association of interest. • In a secondary analysis, the results were stratified by nodal status.

RESULTS

• The crude hazard ratio (HR), which is a measure of relative risk, was not statistically significantly associated with a reduction in the risk of prostate cancer mortality as the number of lymph nodes removed at PLND increased (HR: 0.97, 95% CI: 0.91-1.03). • None of the variables considered as potential confounders had an impact on the crude HR. Using two cut points to categorize the number of lymph nodes removed, one at 4 or more removed and the other at 10 or more removed resulted in HRs indicating a risk reduction of 25% in both cases, although these results were not statistically significant. • When we analyzed the association by pathological nodal status, we observed a possible increase in risk in the node-positive group (HR: 1.10, 95% CI: 0.86, 1.42), while those with negative lymph nodes may have benefited from increasing numbers removed (HR 0.95, 95% CI: 0.89,1.02).

CONCLUSION

• The results of this study indicate a possible therapeutic benefit of lymph node removal in node negative patients. Future research should focus on gaining a better understanding of the biologic mechanisms of a possible therapeutic benefit of PLND, particularly for those lower risk patients with histologically negative lymph nodes.

Hospice use and high-intensity care in men dying of prostate cancer

BACKGROUND

Hospice programs improve the quality of life and quality of death for men dying of cancer. We sought to characterize hospice use by men dying of prostate cancer and to compare the use of high-intensity care between those who did or did not enroll in hospice.

METHODS

We used linked Surveillance, Epidemiology, and End Results-Medicare data to identify a cohort of Medicare beneficiaries who died of prostate cancer between 1992 and 2005. We created 2 multivariable logistic regression models, one to identify factors associated with hospice use and one to determine the association of hospice use with the receipt of diagnostic and interventional procedures and physician visits at the end of life.

RESULTS

Of 14,521 men dying of prostate cancer, 7646 (53%) used hospice for a median of 24 days. Multivariable modeling demonstrated that African American ethnicity (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.68-0.88) and higher Charlson comorbidity index (OR, 0.49; 95% CI, 0.44-0.55) were associated with lower odds of hospice use, while having a partner (OR, 1.23; 95% CI, 1.14-1.32) and more recent year of death (OR, 1.12; 95% CI, 1.11-1.14) were associated with higher odds of hospice use. Men dying of prostate cancer who enrolled in hospice were less likely (OR, 0.82; 95% CI, 0.74-0.91) to receive high-intensity care, including intensive care unit admissions, inpatient stays, and multiple emergency department visits.

CONCLUSIONS

The proportion of individuals using hospice is increasing, but the timing of hospice referral remains poor. Those who enroll in hospice are less likely to receive high-intensity end-of-life care.

The non-breast-cancer death rate among breast cancer patients

Non-breast-cancer deaths currently account for almost half of deaths among breast carcinoma patients in the 15 years following diagnosis. Understanding the trends of non-breast-cancer death is vital for calibrating treatment and survival expectations, and for understanding the consequences of potentially toxic therapies. To observe trends over time in non-breast-cancer relative survival-the non-breast-cancer survival rates of breast cancer patients relative to the non-breast-cancer survival rates of the population as a whole, matched for gender, race, age, region, and year of diagnosis. Non-breast-cancer relative survival between breast carcinoma patients and the general population was measured using SEER public-use data of patients diagnosed with breast carcinoma between 1973 and 2007. Non-breast-cancer relative survival improved significantly from 1973 to the present. From 1986 onward, the non-breast-cancer survival rate among breast carcinoma patients is equal to, or slightly higher than, matched populations who did not have breast carcinoma. This improvement over time occurred across almost all patient stratifications, including race, age, tumor size, and nodal status. However, patients receiving full mastectomies, and patients not receiving radiotherapy experienced no increase in relative survival. The most dramatic relative survival improvements occurred in patients who received radiation and patients receiving partial mastectomies, and such improvements were seen even after controlling for changes in tumor size over time. Non-breast-cancer relative survival among breast carcinoma patients has improved significantly since 1973; breast cancer patients are currently no more likely to die of other causes than the general population.

Vitamin D pathway gene variants and prostate cancer prognosis

BACKGROUND

Observational studies linking vitamin D deficiency with increased prostate cancer (PCa) mortality and the pleiotropic anticancer effects of vitamin D in malignant prostate cell lines have initiated trials examining potential therapeutic benefits of vitamin D metabolites. There have been some successes but efforts have been hindered by risk of inducing hypercalcemia. A limited number of studies have investigated associations between variants in vitamin D pathway genes with aggressive forms of PCa. Increased understanding of relevant germline genetic variation with disease outcome could aid in the development of vitamin-D-based therapies.

METHODS

We undertook a comprehensive analysis of 48 tagging single-nucleotide polymorphisms (tagSNPs) in genes encoding for vitamin D receptor (VDR), vitamin D activating enzyme 1-alpha-hydroxylase (CYP27B1), and deactivating enzyme 24-hydroxylase (CYP24A1) in a cohort of 1,294 Caucasian cases with an average of 8 years of follow-up. Disease recurrence/progression and PCa-specific mortality risks were estimated using adjusted Cox proportional hazards regression.

RESULTS

There were 139 cases with recurrence/progression events and 57 cases who died of PCa. Significantly altered risks of recurrence/progression were observed in relation to genotype for two VDR tagSNPs (rs6823 and rs2071358) and two CYP24A1 tagSNPs (rs927650 and rs2762939). Three VDR tagSNPs (rs3782905, rs7299460, and rs11168314), one CYP27B1 tagSNP (rs3782130), and five CYP24A1 tagSNPs (rs3787557, rs4809960, rs2296241, rs2585428, and rs6022999) significantly altered risks of PCa death.

CONCLUSIONS

Genetic variations in vitamin D pathway genes were found to alter both risk of recurrence/progression and PCa-specific mortality.

Should cause of death from the death certificate be used to examine cancer-specific survival? A study of patients with distant stage disease

Death certificates are used to classify cause of death for studies of cancer survival and mortality. Using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program, we evaluated cause of death (site-specific, cancer cause-specific, or other cause of death) for 229,181 patients with distant stage disease during 1994-2003 who died by 2005. Agreement between coded cause of death and initial diagnosis was 85% in patients with only one primary and 64% in patients with more than one primary. Our findings support the usefulness of site and cancer cause-specific causes of death reported on the death certificate for distant stage patients with a single cancer.

Racial differences in treatment and outcomes among patients with early stage bladder cancer

BACKGROUND

Black patients are at greater of risk of death from bladder cancer than white patients. Potential explanations for this disparity include a more aggressive phenotype and delays in diagnosis resulting in higher stage disease. Alternatively, black patients may receive a lower quality of care, which may explain this difference.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the years from 1992 through 2002, the authors identified patients with early stage bladder cancer. Multivariate models were fitted to measure relations between race and mortality, adjusting for differences in patients and treatment intensity. Next, shared-frailty proportional hazards models were fitted to evaluate whether the disparity was explained by differences in the quality of care provided.

RESULTS

Compared with white patients (n = 14,271), black patients (n = 342) were more likely to undergo restaging resection (12% vs 6.5%; P < .01) and urine cytologic evaluation (36.8% vs 29.7%; P < .01), yet they received fewer endoscopic evaluations (4 vs 5; P < .01). The use of aggressive therapies (cystectomy, systemic chemotherapy, radiation) was found to be similar among black patients and white patients (12% vs 10.2%, respectively; P = .31). Although black patients had a greater risk of death compared with white patients (hazards ratio [HR], 1.23; 95% confidence interval [95% CI], 1.07-1.42), this risk was attenuated only modestly after adjusting for differences in treatment intensity and provider effects (HR, 1.22; 95% CI, 1.06-1.42).

CONCLUSIONS

Although differences in initial treatment were evident, they did not appear to be systematic and had unclear clinical significance. Whereas black patients are at greater risk of death, this disparity did not appear to be caused by differences in the intensity or quality of care provided.

Should bladder cuff excision remain the standard of care at nephroureterectomy in patients with urothelial carcinoma of the renal pelvis? A population-based study

BACKGROUND

A large, multi-institutional, tertiary care center study suggested no benefit from bladder cuff excision (BCE) at nephroureterectomy in patients with upper tract urothelial carcinoma (UC).

OBJECTIVE

We tested and quantified the prognostic impact of BCE at nephroureterectomy on cancer-specific mortality (CSM) in a large population-based cohort of patients with UC of the renal pelvis.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of 4210 patients with UC of the renal pelvis were treated with nephroureterectomy with (NUC) or without (NU) a BCE between 1988 and 2006 within 17 Surveillance, Epidemiology, and End Results registries.

MEASUREMENTS

Cumulative incidence plots and competing risks regression models compared CSM after either NUC or NU. Covariates consisted of pathologic T and N stages, grade, age, year of surgery, gender, and race.

RESULTS AND LIMITATIONS

Respectively, 2492 (59.2%) and 1718 (40.8%) patients underwent a nephroureterectomy with or without BCE. In univariable and multivariable analyses, BCE omission increased CSM rates in patients with pT3N0/x, pT4N0/x, and pT(any)N1-3 UC of the renal pelvis. For example, in patients with pT3N0/x disease, holding all other variables constant, BCE omission increased CSM in a 1.25-fold fashion (p=0.04). Similarly, in patients with pT4N0/x disease, BCE omission resulted in a 1.45-fold increase (p=0.02). The main limitation of our study is the lack of data on disease recurrence.

CONCLUSIONS

Nephroureterectomy with BCE remains the standard of care in the treatment of UC of the renal pelvis and should invariably be performed in patients with locally advanced disease. Conversely, patients with pT1 and pT2 disease could be considered for NU without compromising CSM. However, recurrence data are needed to fully confirm the validity of this option.

Recent time trends in the epidemiology of stage IV prostate cancer in the United States: analysis of data from the Surveillance, Epidemiology, and End Results Program

OBJECTIVES

To describe recent epidemiologic trends in stage IV prostate cancer. Although advances in screening and diagnostic techniques have led to earlier detection of prostate cancer, a portion of patients still present with late-stage disease.

METHODS

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results Program (cases from 1988 to 2003, follow-up through 2005) were used to calculate annual age-adjusted incidence rates of stage IV prostate cancer (overall and for the subset presenting with distant metastases) and to assess time trends in patient, tumor, and treatment characteristics and survival.

RESULTS

From 1988 to 2003, the age-adjusted incidence of stage IV prostate cancer significantly declined by 6.4% each year. The proportion of men diagnosed at younger ages, with poorly differentiated tumors, or who underwent a radical prostatectomy significantly increased over time. Five-year relative survival improved across the study period (from 41.6% to 62.3%), particularly in those diagnosed at younger ages or with moderately to well-differentiated tumors. Later years of diagnosis were independently associated with a decreased risk of death (from all causes and from prostate cancer specifically) after controlling for important patient, tumor, and treatment characteristics. Tumor grade and receipt of radical prostatectomy appeared to be the strongest independent prognostic indicators. Temporal trends were similar in the subset presenting with distant metastases, except that no significant improvement in survival was observed.

CONCLUSIONS

As younger men may expect to live longer with advanced prostate cancer, there remains a need to widen the range of therapeutic and supportive care options.

Gender-related differences in patients with stage I to III upper tract urothelial carcinoma: results from the Surveillance, Epidemiology, and End Results database

OBJECTIVES

To examine the effect of gender in upper tract urothelial carcinoma (UTUC) stage at nephroureterectomy (NU), as well as on cancer-specific mortality (CSM) after NU in patients with American Joint Committee on Cancer stages I-III UTUC.

METHODS

Our analyses relied on 2903 (59.9%) males and 1947 (40.1%) females who underwent an NU for pT(1-3)N(0/x)M(0) UTUC between 1988 and 2006, within 17 Surveillance, Epidemiology, and End Results registries. Univariable and multivariable logistic regression models examined the effect of gender on stage and grade distribution at NU. Subsequently, cumulative incidence plots explored the impact of gender on CSM rates, after accounting for other-cause mortality (OCM). Finally, competing-risks regression models tested the independent predictor status of gender in CSM analyses. Covariates consisted of pT stage, pN stage, tumor grade, primary tumor location, type and year of surgery, age, and race.

RESULTS

Relative to males, females had a higher proportion of pT(3) UTUC (43.1% vs 39%; P = .02) and a higher proportion of grade III/IV UTUC (63.8% vs 59.8%; P = .04) at NU. The female gender represented an independent predictor of pT(3) UTUC at NU (hazard ratio [HR]: 1.15; P = .03). After accounting for OCM, CSM rates in females were higher than those in males (HR: 1.18; P = .03). However, in multivariable competing-risks regression models, no statistically significant differences in survival were recorded between males and females (HR: 1.07; P = .4).

CONCLUSIONS

Females are more likely to have more advanced pathologic T stage and higher tumor grade at NU than males. After accounting for OCM, stage, grade, and noncancer characteristics, gender no longer affects CSM.

Outcomes of localized prostate cancer following conservative management

CONTEXT

Most newly diagnosed prostate cancers are clinically localized, and major treatment options include surgery, radiation, or conservative management. Although conservative management can be a reasonable choice, there is little contemporary prostate-specific antigen (PSA)-era data on outcomes with this approach.

OBJECTIVE

To evaluate the outcomes of clinically localized prostate cancer managed without initial attempted curative therapy in the PSA era.

DESIGN, SETTING, AND PARTICIPANTS

A population-based cohort study of men aged 65 years or older when they were diagnosed (1992-2002) with stage T1 or T2 prostate cancer and whose cases were managed without surgery or radiation for 6 months after diagnosis. Living in areas covered by the Surveillance, Epidemiology, and End Results (SEER) program, the men were followed up for a median of 8.3 years (through December 31, 2007). Competing risk analyses were performed to assess outcomes.

MAIN OUTCOME MEASURES

Ten-year overall survival, cancer-specific survival, and major cancer related interventions.

RESULTS

Among men who were a median age of 78 years at cancer diagnosis, 10-year prostate cancer-specific mortality was 8.3% (95% confidence interval [CI], 4.2%-12.8%) for men with well-differentiated tumors; 9.1% (95% CI, 8.3%-10.1%) for those with moderately differentiated tumors, and 25.6% (95% CI, 23.7%-28.3%) for those with poorly differentiated tumors. The corresponding 10-year risks of dying of competing causes were 59.8% (95% CI, 53.2%-67.8%), 57.2% (95% CI, 52.6%-63.9%), and 56.5% (95% CI, 53.6%-58.8%), respectively. Ten-year disease-specific mortality for men aged 66 to 74 years diagnosed with moderately differentiated disease was 60% to 74% lower than earlier studies: 6% (95% CI, 4%-8%) in the contemporary PSA era (1992-2002) compared with results of previous studies (15%-23%) in earlier eras (1949-1992). Improved survival was also observed in poorly differentiated disease. The use of chemotherapy (1.6%) or major interventions for spinal cord compression (0.9%) was uncommon.

CONCLUSIONS

Results following conservative management of clinically localized prostate cancer diagnosed from 1992 through 2002 are better than outcomes among patients diagnosed in the 1970s and 1980s. This may be due, in part, to additional lead time, overdiagnosis related to PSA testing, grade migration, or advances in medical care.

Provider treatment intensity and outcomes for patients with early-stage bladder cancer

BACKGROUND

Bladder cancer is among the most prevalent and expensive to treat cancers in the United States. In the absence of high-level evidence to guide the optimal management of bladder cancer, urologists may vary widely in how aggressively they treat early-stage disease. We examined associations between initial treatment intensity and subsequent outcomes.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients who were diagnosed with early-stage bladder cancer from January 1, 1992, through December 31, 2002 (n = 20 713), and the physician primarily responsible for providing care to each patient (n = 940). We ranked the providers according to the intensity of treatment they delivered to their patients (as measured by their average bladder cancer expenditures reported to Medicare in the first 2 years after a diagnosis) and then grouped them into quartiles that contained approximately equal numbers of patients. We assessed associations between treatment intensity and outcomes, including survival through December 31, 2005, and the need for subsequent major interventions by using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

The average Medicare expenditure per patient for providers in the highest quartile of treatment intensity was more than twice that for providers in the lowest quartile of treatment intensity ($7131 vs $2830, respectively). High-treatment intensity providers more commonly performed endoscopic surveillance and used more intravesical therapy and imaging studies than low-treatment intensity providers. However, the intensity of initial treatment was not associated with a lower risk of mortality (adjusted hazard ratio of death from any cause for patients of low- vs high-treatment intensity providers = 1.03, 95% confidence interval 0.97 to 1.09). Initial intensive management did not obviate the need for later interventions. In fact, a higher proportion of patients treated by high-treatment intensity providers than by low-treatment intensity providers subsequently underwent a major medical intervention (11.0% vs 6.4%, P = .02).

CONCLUSIONS

Providers vary widely in how aggressively they manage early-stage bladder cancer. Patients treated by high-treatment intensity providers do not appear to benefit in terms of survival or in avoidance of subsequent major medical interventions.

Feasibility and cost of obtaining informed consent for essential review of medical records in large-scale health services research

Objective:

To evaluate the effectiveness and cost of obtaining consent for review of medical records within the passively observed non-intervention arm of a cluster randomized controlled trial, ‘Comparison Arm for ProtecT’.

Methods:

Two hundred and thirty men, who had been notified to the trial by cancer registries as having prostate cancer, were sent a consent form from their general practitioner or secondary care clinician. The consent rate of participants to the review of their medical records and the estimated costs of the process were evaluated.

Results:

One hundred and seventy-nine men (84%: 95% CI = 78%, 89%) consented to have their medical notes reviewed at an estimated cost of £123 (€172, $248) per person.

Conclusions:

A high consent rate for review of medical notes is achievable but at a cost. There needs to be renewed debate about the automatic need for consent to review medical records where the chance of personal harm is negligible and the purpose of the review is to provide robust evidence to save lives, prevent needless suffering, and improve the effectiveness and efficiency of health care delivery.

Reliability of death certificates in prostate cancer patients

OBJECTIVE

To evaluate the reliability of cause-of-death diagnoses among prostate cancer patients.

MATERIAL AND METHODS

Information from death certificates obtained from the Swedish Death Register was compared with systematically reviewed medical records from the population-based Swedish Regional Prostate Cancer Register, South-East Region. In total, 5675 patients were included who had been diagnosed with prostate cancer between 1987 and 1999 and who had died before 1 January 2003.

RESULTS

The proportion of prostate cancer cases classified as having died from prostate cancer was 3% higher in the official death certificates than in the reviewed records [0.03, 95% confidence interval (CI) 0.02 to 0.04]. Overall agreement between the official cause of death and the reviewed data was 86% (95% CI 85 to 87%). A higher accuracy was observed among men with localized disease (88%, 95% CI 87 to 89%), aged 60 years or younger at death (96%, 95% CI 93 to 100%), or who had undergone curative treatment (91%, 95% CI 88 to 95%). This study indicates a relatively high reliability of official cause-of-death statistics of prostate cancer patients in Sweden.

CONCLUSION

Mortality data obtained from death certificates may be useful in the evaluation of large-scale prostate cancer intervention programmes, especially among younger patients with localized disease.

Cause of death in older men after the diagnosis of prostate cancer

OBJECTIVES

To compare survival and cause of death in men aged 65 and older diagnosed with prostate cancer and with survival and cause of death in a noncancer control population.

DESIGN

Retrospective cohort from a population-based tumor registry linked to Medicare claims data.

SETTING

Eleven regions of the Surveillance, Epidemiology and End Results (SEER) Tumor Registry.

PARTICIPANTS

Men aged 65 to 84 (N=208,601) diagnosed with prostate cancer from 1988 through 2002 formed the basis for different analytical cohorts.

MEASUREMENTS

Survival as a function of stage and tumor grade (low, Gleason grade<7; moderate, grade=7; and high, grade=8-10) was compared with survival in men without any cancer using Cox proportional hazards regression. Cause of death according to stage and tumor grade were compared using chi-square statistics.

RESULTS

Men with early-stage prostate cancer and with low- to moderate-grade tumors (59.1% of the entire sample) experienced a survival not substantially worse than men without prostate cancer. In those men, cardiovascular disease and other cancers were the leading causes of death.

CONCLUSION

The excellent survival of older men with early-stage, low- to moderate-grade prostate cancer, along with the patterns of causes of death, implies that this population would be well served by an ongoing focus on screening and prevention of cardiovascular disease and other cancers.

Survival following primary androgen deprivation therapy among men with localized prostate cancer

CONTEXT

Despite a lack of data, increasing numbers of patients are receiving primary androgen deprivation therapy (PADT) as an alternative to surgery, radiation, or conservative management for the treatment of localized prostate cancer.

OBJECTIVE

To evaluate the association between PADT and survival in elderly men with localized prostate cancer.

DESIGN, SETTING, AND PATIENTS

A population-based cohort study of 19,271 men aged 66 years or older receiving Medicare who did not receive definitive local therapy for clinical stage T1-T2 prostate cancer. These patients were diagnosed in 1992-2002 within predefined US geographical areas, with follow-up through December 31, 2006, for all-cause mortality and through December 31, 2004, for prostate cancer-specific mortality. Instrumental variable analysis was used to address potential biases associated with unmeasured confounding variables.

MAIN OUTCOME MEASURES

Prostate cancer-specific survival and overall survival.

RESULTS

Among patients with localized prostate cancer (median age, 77 years), 7867 (41%) received PADT, and 11,404 were treated with conservative management, not including PADT. During the follow-up period, there were 1560 prostate cancer deaths and 11,045 deaths from all causes. Primary androgen deprivation therapy was associated with lower 10-year prostate cancer-specific survival (80.1% vs 82.6%; hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.03-1.33) and no increase in 10-year overall survival (30.2% vs 30.3%; HR, 1.00; 95% CI, 0.96-1.05) compared with conservative management. However, in a prespecified subset analysis, PADT use in men with poorly differentiated cancer was associated with improved prostate cancer-specific survival (59.8% vs 54.3%; HR, 0.84; 95% CI, 0.70-1.00; P = .049) but not overall survival (17.3% vs 15.3%; HR, 0.92; 95% CI, 0.84-1.01).

CONCLUSION

Primary androgen deprivation therapy is not associated with improved survival among the majority of elderly men with localized prostate cancer when compared with conservative management.

Death certificates provide an adequate source of cause of death information when evaluating lung cancer mortality: an example from the Mayo Lung Project

To assess the accuracy of death certificates in assigning lung cancer as the underlying cause of death, death certificate data were compared to mortality review committee-determined causes of death among participants in the Mayo Lung Project. Further, the impact of death certificate misclassification on lung cancer mortality rates and Cox proportional hazards models was evaluated. The Mayo Lung Project (1971-1983) was a randomized controlled trial of lung cancer screening; participants were male smokers aged 45 years and older who were seen as outpatients at the Mayo Clinic in Rochester, Minnesota. Overall there were 237 lung cancer deaths according to mortality review, and 224 according to the death certificate (sensitivity 88.6 percent, 95 percent confidence interval (CI) 83.9, 92.4; specificity 99.1 percent, 95 percent CI 98.6, 99.5). As compared to the mortality review committee's determination, the use of death certificate data resulted only in slight decreases to the calculated lung cancer mortality rates for each screening arm, and did not result in appreciable changes to hazard ratios for lung cancer mortality in Cox regression models. In these data, death certificates were sufficiently sensitive and specific such that their use did not result in a meaningful change to mortality-based outcomes.

Dying with cancer: the influence of age, comorbidity, and cancer site

BACKGROUND

Cancer survival is influenced by age, comorbidity, and type of cancer. A population-based study was conducted to compare the interplay between age and mortality for different cancers.

METHODS

This study analyzed 784,378 cases, comprising 22 of the commonest SEER cancers diagnosed between 1984 and 1993. Competing hazards and proportional hazard analyses for cancer-specific and comorbid death were performed.

RESULTS

Median follow-up was up to 159 months, and the median age of diagnosis was 67 years. Cancer-specific and comorbid deaths accumulated most within the first years of diagnosis. With the more biologically aggressive cancers, cancer deaths invariably exceeded comorbid deaths. For the remaining 70% of cancers, comorbidity remained the dominant mode of death. Deaths attributable to both cancer and comorbidity accumulated mostly after the seventh decade of life. Cancer site had a 3-fold greater effect on overall survival than age at diagnosis and a 30-fold effect with cancer-specific survival; age at diagnosis had a 5-fold greater effect on comorbid deaths than site.

CONCLUSIONS

Both the age of the affected individual and the biology of the particular cancer have major influences on cancer survival and mode of death. Cancer is largely a disease of the elderly. Within affected individuals, fatalities attributable to cancer and comorbidity appeared inter-related, with cancer-specific deaths dominating for more lethal cancers and comorbid deaths dominating for the remaining majority. For these reasons, further improvements in overall survival may be best anticipated from better geriatric and general medical management as much as from better cancer management.

Short-Term Neoadjuvant Androgen Deprivation Therapy and External-Beam Radiotherapy for Locally Advanced Prostate Cancer: Long-Term Results of RTOG 8610

Purpose

Radiation Therapy Oncology Group (RTOG) 8610 was the first phase III randomized trial to evaluate neoadjuvant androgen deprivation therapy (ADT) in combination with external-beam radiotherapy (EBRT) in men with locally advanced prostate cancer. This report summarizes long-term follow-up results.

Materials and Methods

Between 1987 and 1991, 456 assessable patients (median age, 70 years) were enrolled. Eligible patients had bulky (5 × 5 cm) tumors (T2-4) with or without pelvic lymph node involvement according to the 1988 American Joint Committee on Cancer TNM staging system. Patients received combined ADT that consisted of goserelin 3.6 mg every 4 weeks and flutamide 250 mg tid for 2 months before and concurrent with EBRT, or they received EBRT alone. Study end points included overall survival (OS), disease-specific mortality (DSM), distant metastasis (DM), disease-free survival (DFS), and biochemical failure (BF).

Results

Ten-year OS estimates (43% v 34%) and median survival times (8.7 v 7.3 years) favored ADT and EBRT, respectively; however, these differences did not reach statistical significance (P = .12). There was a statistically significant improvement in 10-year DSM (23% v 36%; P = .01), DM (35% v 47%; P = .006), DFS (11% v 3%; P < .0001), and BF (65% v 80%; P < .0001) with the addition of ADT, but no differences were observed in the risk of fatal cardiac events.

Conclusion

The addition of 4 months of ADT to EBRT appears to have a dramatic impact on clinically meaningful end points in men with locally advanced disease with no statistically significant impact on the risk of fatal cardiac events.

Secular trends in prostate cancer mortality, incidence and treatment: England and Wales, 1975-2004

OBJECTIVE

To aid the interpretation of the trends in prostate cancer mortality, which declined in the UK in the early 1990 s for unknown reasons, by investigating prostate cancer death rates, incidence and treatments in England and Wales in 1975-2004.

METHODS

Join-point regression was used to assess secular trends in mortality and incidence (source: Office of National Statistics), radical prostatectomy and orchidectomy (source: Hospital Episode Statistics database) and androgen-suppression drugs (source: Intercontinental Medical Statistics).

RESULTS

Prostate cancer mortality declined from 1992 (95% confidence interval, CI, 1990-94). The relative decline in mortality to 2004 was greater and more sustained amongst men aged 55-74 years (annual percentage mortality reduction 2.75%; 95% CI 2.33-3.18%) than amongst those aged >or=75 years (0.71%, 0.26-1.15%). The use of radical prostatectomy increased between 1991 (89 operations) and 2004 (2788) amongst men aged 55-74 years. The prescribing of androgen suppression increased between 1987 (33,000 prescriptions) and 2004 (470,000).

CONCLUSIONS

The decrease in prostate cancer mortality was greater amongst men aged 55-74 years than in those aged >or=75 years, but pre-dated the substantial use of prostate-specific antigen screening and radical prostatectomy in the UK. An increase in radical therapy amongst younger groups with localized cancers and screen-detected low-volume locally advanced disease as a result of stage migration, as well as prolonged survival from increased medical androgen suppression therapy, might partly explain recent trends.

Assessment of causes of death in a prostate cancer screening trial

Accurate assessment of the causes of death is crucial for a conclusive evaluation of the ongoing prostate cancer screening trials. Here, we report the validity of the official causes of death as compared with an independent expert review in the Finnish prostate cancer screening trial. Because nearly 80,000 men were involved, death-cause evaluation was restricted to men diagnosed for prostate cancer. Medical charts were retrieved and the cause of death was assigned by an expert review panel for all deaths among men with prostate cancer during the study period, 1996-2003. The panel decision was compared with both death certificates and the official causes of death as assigned by Statistics Finland. Of a total of 315 deaths, the review panel attributed 127 (41%) to prostate cancer and 184 (59%) to other causes, the corresponding figures in death certificates being 124 (40%) and 187 (60%). Four cases were excluded because of insufficient information. The death-certificate data were in agreement with the panel's assessment in 305 out of 311 cases (overall agreement 97.7%, kappa = 0.95). The overall agreement between the official causes of death and the panel's decision was 97.4% (304/311, kappa = 0.95). The sensitivity of the certificates in identifying prostate cancer deaths was 96.1% (panel as golden standard). Correspondingly, specificity was 98.9%. The official causes of death thus provide an accurate means for evaluating disease-specific mortality in a large population-based prostate-cancer screening trial in Finland.

Differences in prognostic factors and survival among white and Asian men with prostate cancer, California, 1995-2004

BACKGROUND

There are very limited data concerning survival from prostate cancer among Asian subgroups living in the U.S., a large proportion of whom reside in California. There do not appear to be any published data on prostate cancer survival for the more recently immigrated Asian subgroups (Korean, South Asian [SA], and Vietnamese).

METHODS

A study of prognostic factors and survival from prostate cancer was conducted in non-Hispanic whites and 6 Asian subgroups (Chinese, Filipino, Japanese, Korean, SA, and Vietnamese), using data from all men in California diagnosed with incident prostate cancer during 1995-2004 and followed through 2004 (n = 116,916). Survival was analyzed using Cox proportional hazards models.

RESULTS

Whites and Asians demonstrated significant racial differences in all prognostic factors: age, summary stage, primary treatment, histologic grade, socioeconomic status, and year of diagnosis. Every Asian subgroup had a risk factor profile that put them at a survival disadvantage compared with whites. Overall, the 10-year risk of death from prostate cancer was 11.9%. However, in unadjusted analyses Japanese men had significantly better survival than whites; Chinese, Filipino, Korean, and Vietnamese men had statistically equal survival; and SA men had significantly lower survival. On multivariate analyses adjusting for all prognostic factors, all subgroups except SA and Vietnamese men had significantly better survival than whites; the latter 2 groups had statistically equal survival.

CONCLUSIONS

Traditional prognostic factors for survival from prostate cancer do not explain why most Asian men have better survival compared with whites, but they do explain the poorer survival of SA men compared with whites.

Cause of death in patients with end-stage renal disease: assessing concordance of death certificates with registry reports

OBJECTIVES

To assess concordance in reporting, in two Australian national datasets, of cause of death of patients with end-stage renal disease (ESRD).

METHODS

For deaths in 1997-99, we compared 'cause of death' and 'primary renal disease', as coded in the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), with 'underlying' and 'associated' causes of death (based on death certificates), as coded by the Australian Bureau of Statistics (ABS). Dates of birth and death and sex identified the same individuals in the two datasets. Deaths from the three States for which date of birth was not available from death certificates were excluded. Cause of death was compared at the ICD-10 chapter level.

RESULTS

Of 1,728 ANZDATA patients from NSW, SA, WA, NT and ACT who died during 1997-99, 1,117 (65%) could be matched to a record in the ABS dataset for the corresponding jurisdictions. The death certificates of 219 (20%) of these 1,117 patients made no mention of chronic renal failure. Overall, agreement on cause of death was poor (kappa = 0.22). Using ANZDATA information on cause of death and ABS underlying cause of death, only 38% of patients had the same cause (at the ICD-10 chapter level) recorded in both datasets. Additional information on primary renal disease (ANZDATA) and up to 12 associated causes of death (ABS) was required to obtain substantial agreement.

CONCLUSION AND IMPLICATIONS

Death certificates and ANZDATA records provide differing causes of death for ESRD patients. Information from these sources was not directly comparable. Neither dataset provided a complete picture of renal disease as a cause of death in Australia.

The median non-prostate cancer survival is more than 10 years for men up to age 80 years who are selected and receive curative radiation treatment for prostate cancer

Treatment guidelines recommend that curative radiation treatment of prostate cancer be offered only to men whose life expectancy is greater than 10 years. The average life expectancy of North American males is less than 10 years after age 75, yet many men older than 75 years receive curative radiation treatment for prostate cancer. This study used the provincial cancer registry in British Columbia, Canada, to determine median non-prostate cancer survival for men who were aged 75 to 82 years at start of radiation treatment. Median survival was found to be greater than 10 years in men aged up to 80 years at the start of their radiation treatment. This finding suggests that radiation oncologists are able to appropriately select elderly men with greater than average life expectancy to receive curative radiation treatment.

Predictors of Overall and Cancer-Free Survival of Patients With Localized Prostate Cancer Treated With Primary Androgen Suppression Therapy: Results From the Prostate Cancer Outcomes Study

PURPOSE

Primary androgen suppression therapy for clinically localized prostate cancer is increasingly common in the United States despite a lack of supportive evidence for its use. We determined which demographic and clinical factors predict overall and cancer specific survival with this treatment strategy in patients enrolled in the Prostate Cancer Outcomes Study.

MATERIALS AND METHODS

In 1994 to 1995 the Prostate Cancer Outcomes Study recruited 3,533 men diagnosed with prostate cancer. Clinical and treatment information was abstracted from medical records and demographic characteristics were obtained from patient surveys 6, 12, 24 and 60 months after diagnosis. Overall and cancer specific mortality was analyzed through December 2002 using the Kaplan-Meier method and Cox regression.

RESULTS

A total of 276 patients had organ confined (cT1-2) prostatic adenocarcinoma and received primary androgen suppression therapy within 1 year of diagnosis. Median followup for censored patients was 7.6 years (range 1.1 to 8.1). Five-year overall and cancer specific survival was 66% (95% CI 59-72) and 91% (95% CI 86-94), respectively. Independent predictors of shorter overall survival were patient age 75 years or older, prostate specific antigen 20 ng/ml or greater, Gleason score 7 or greater and abnormal digital rectal examination. Gleason score 7 or greater, prostate specific antigen 20 ng/ml or greater and a low comorbidity index were independent predictors of shorter cancer specific survival.

CONCLUSIONS

The use of primary androgen suppression therapy in the Prostate Cancer Outcomes Study data set resulted in 91% 5-year cancer specific survival. Advanced age, and factors that reflect tumor burden and biology were predictive of overall survival, while cancer specific survival was predicted by tumor factors and the burden of comorbid conditions. A nomogram for predicting overall survival at 5 years was constructed.

Use of hormonal therapy in men with metastatic prostate cancer

PURPOSE

Bilateral orchiectomy or luteinizing hormone releasing hormone agonists represent the standard of care for metastatic prostate cancer. In this population based study we assessed the use rates of these therapies in men who died of prostate cancer.

MATERIAL AND METHODS

A total of 9,110 men 65 years or older who died of prostate cancer in 1991 to 2000 were identified through the population based Surveillance, Epidemiology and End Results, and Medicare linked database to determine hormonal therapy use rates. A modified Poisson regression model was used to estimate the adjusted effects of various factors associated with hormone use.

RESULTS

Approximately 38% of black and 25% of white men did not receive hormonal therapy before dying of prostate cancer. After adjusting for cancer status at diagnosis and other potential confounding factors black race and residence in low income areas were associated with lower hormonal therapy use (relative risk 0.73, 95% CI 0.67 to 0.80 and 0.91, 95% CI 0.85 to 0.98, respectively). Hormonal therapy use was most comprehensive in the Northeast.

CONCLUSIONS

A substantial number of men who die as a consequence of prostate cancer never receive hormonal therapy. The use of hormonal therapy varies significantly. Further studies are warranted to determine factors that may be associated with the incomplete use of hormonal therapy for metastatic prostate cancer.

In search of the perfect comorbidity measure for use with administrative claims data: does it exist?

BACKGROUND

Numerous measures of comorbidity have been developed for health services research with administrative claims.

OBJECTIVE

We sought to compare the performance of 4 claims-based comorbidity measures.

RESEARCH DESIGN AND SUBJECTS

We undertook a retrospective cohort study of 5777 Medicare beneficiaries ages 66 and older with stage III colon cancer reported to the Surveillance, Epidemiology, and End Results Program between January 1, 1992 and December 31, 1996.

MEASURES

Comorbidity measures included Elixhauser's set of 30 condition indicators, Klabunde's outpatient and inpatient indices weighted for colorectal cancer patients, Diagnostic Cost Groups, and the Adjusted Clinical Group (ACG) System. Outcomes included receipt of adjuvant chemotherapy and 2 year noncancer mortality.

RESULTS

For all measures, greater comorbidity significantly predicted lower receipt of chemotherapy and higher noncancer death. Nested logistic regression modeling suggests that using more claims sources to measure comorbidity generally improves the prediction of chemotherapy receipt and noncancer death, but depends on the measure type and outcome studied. All 4 comorbidity measures significantly improved the fit of baseline regression models for both chemotherapy receipt (baseline c-statistic 0.776; ranging from 0.779 after adding ACGs and Klabunde to 0.789 after Elixhauser) and noncancer death (baseline c-statistic 0.687; ranging from 0.717 after adding ACGs to 0.744 after Elixhauser).

CONCLUSIONS

Although some comorbidity measures demonstrate minor advantages over others, each is fairly robust in predicting both chemotherapy receipt and noncancer death. Investigators should choose among these measures based on their availability, comfort with the methodology, and outcomes of interest.

Survival of men with clinically localized prostate cancer treated with prostatectomy, brachytherapy, or no definitive treatment

BACKGROUND

The optimal treatment for men with early stage prostate cancer remains undefined. Survival of such patients after surgery, brachytherapy, or no definitive therapy was investigated specifically to determine the impact of age at diagnosis.

METHODS

In all, 60,290 men diagnosed with organ-confined, low and moderate grade prostate cancer between 1988 and 2002 were retrospectively identified from centers participating in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. Prostate cancer-specific mortality (PCSM) and any-cause mortality (ACM) were determined. Outcomes for patients treated by brachytherapy, surgery, or receiving no definitive treatment were compared using the Wilcoxon test, stratified by T-stage and grade, and using multivariate analysis.

RESULTS

The median follow-up time was 46 months (range, 0-189 months). For men under age 60 at diagnosis, PCSM at 10 years was 1.3%, 0.5%, and 3.7% for surgery, brachytherapy, and no definitive therapy, respectively. For men age 60 and older the PCSM was 3.8%, 5.3%, and 8.4%, respectively. On univariate and multivariate analysis, surgery and brachytherapy resulted in statistically equivalent PCSM and ACM, and both had a significantly lower PCSM and ACM versus no definitive therapy.

CONCLUSIONS

A better survival was observed in men treated with a definitive therapy. The magnitude of the benefit on PCSM or ACM was similar for both definitive therapies irrespective of age.

High prostate cancer mortality in Norway: Influence of Cancer Registry information?

Norway has among the highest prostate cancer mortality rates in the world. The aim of the present project was to assess whether this can be explained by the unique routine procedure of information transfer from the Cancer Registry of Norway (CR) to the Norwegian Cause of Death Registry (COD Registry). Norwegian prostate cancer patients deceased during 1996 were identified (n=2012). The information basis of the official mortality statistics was reviewed by two physicians, who independently identified the underlying cause of death, primarily prostate cancer or not, supplemented by consensus of two other physicians. The coding was done in two steps; first without, then with CR information. Project physicians identified 1063 deaths from prostate cancer as compared to the official number of 1161, with discrepancy as to prostate cancer death in 126 deceased. Information from the CR increased the project's age-adjusted (world standard population) prostate cancer mortality rate by less than 1% (from 22.7 to 22.9 per 100,000). In conclusion, the high rates of prostate cancer mortality in Norway could not be explained by information transfer from the CR to the COD Registry.

CHANGING PATTERNS IN COMPETING CAUSES OF DEATH IN MEN WITH PROSTATE CANCER: A POPULATION BASED STUDY

PURPOSE

We examined trends in hospitalization and death in men with prostate cancer to determine whether outcomes have changed with time in men diagnosed and treated for this disorder.

MATERIALS AND METHODS

A population based cohort study of 180973 patients with prostate cancer in the 1979 to 1996 Surveillance, Epidemiology and End Results cancer registry and 450448 admissions in the 1987 to 1996 Surveillance, Epidemiology and End Results-Medicare linked database were analyzed. ORs derived from logistic regression were used to assess time trends in mortality and hospitalization. Multinominal logistic regression was used to obtain the adjusted proportions of deaths due to various causes in different years.

RESULTS

In men with prostate cancer the risk of death from cancer was 39.7% (OR = 0.61, 95% CI = 0.56 to 0.66), which was lower in 1995 to 1996 than in 1979 to 1980. Decreases in prostate cancer death were greater than those in cardiovascular disorders (OR = 0.85, 95% CI = 0.78 to 0.92) and evident even in men with nonlocalized disease. Overall nonprostate cancer causes of mortality increased (OR = 1.65, 95% CI = 1.52 to 1.79) and ultimately exceeded that due to prostate cancer. By 1995 to 1996 the proportion of prostate cancer deaths was similar to that of cardiovascular disorders (27.7% and 26.6%, respectively) and substantially less than that of all other sources combined (45.7%). Similar effects were observed for prostate cancer (OR = 0.40, 95% CI = 0.37 to 0.42) and nonprostate cancer (OR = 2.51, 95% CI = 2.36 to 2.68) hospitalizations.

CONCLUSIONS

In men with prostate cancer decreases in prostate cancer hospitalization and mortality have been greater than those in competing diseases with time. Most deaths in patients with prostate cancer, including those with nonlocalized disease, are now due to nonprostate cancer causes.