Population Based Study of Hormonal Therapy and Survival in Men With Metastatic Prostate Cancer

Economic evaluation of diagnostic localization following biochemical prostate cancer recurrence

OBJECTIVES

The aim of this study was to assess potential cost-effectiveness of using a prostate cancer specific functional imaging technology capable of identifying residual localized disease versus small volume metastatic disease for asymptomatic men with low but detectable prostate specific antigen (PSA) elevation following radical prostatectomy.

METHODS

Markov modeling was used to estimate the incremental impact on healthcare system costs (2012 USD) and quality-adjusted life-years (QALYs) of two alternative strategies: (i) using the new diagnostic to guide therapy versus (ii) current usual care-using a combination of computed tomography, magnetic resonance imaging, and bone scan to guide therapy. Costs were based on estimates from literature and Medicare reimbursement. Prostate cancer progression, survival, utilities, and background risk of all-cause mortality were obtained from literature. Base-case diagnostic sensitivity (75 percent), specificity (90 percent), and cost (USD 2,500) were provided by our industry partner GE Healthcare.

RESULTS

The new diagnostic strategy provided an average gain of 1.83 (95 percent uncertainty interval [UI]: 1.24-2.64) QALYs with added costs of USD 15,595 (95 percent UI: USD -6,330-44,402) over 35 years. The resulting incremental cost-effectiveness ratio was USD 8,516/QALY (95 percent UI: USD -2,947-22,372). RESULTS were most influenced by the utility discounting rate and test performance characteristics; however, the new diagnostic provided clinical benefits over a wide range of sensitivity and specificity.

CONCLUSION

This analysis suggests a diagnostic technology capable of identifying whether men with biochemical recurrence after radical prostatectomy have localized versus metastatic disease would be a cost-effective alternative to current standard work-up. The results support additional investment in development and validation of such a diagnostic.

[Stage IV prostate cancer in Guadeloupe, a French Caribbean archipelago]

OBJECTIVES

To study clinical characteristics, in terms of survival and response to treatment, of patients with non-localized prostate cancer at diagnosis in an Afro-Caribbean population from Guadeloupe.

METHODS

Cases of stage IV prostate cancer (T4N0M0, TxN1M0 and TxNxM1) at diagnosis in the Pointe à Pitre Hospital were selected from 1995 to 2012 and studied.

RESULTS

One hundred and eighty-three patients were included. Median age at diagnosis was 70.3 years old (79.2% were more than 65 years). A total of 81.5% of them was TxNxM1 and 11.5% was TxN1M0. Median disease free survival was 18.5 months. Median overall survival was 49.0 months.

CONCLUSION

This study about non-localized prostate cancer at diagnosis in an Afro-Caribbean population from a French Caribbean archipelago seemed to show no difference with general population suffering from the same disease, although prostate cancer incidence in this area is one of the highest in the world.

Effect of urologists and medical oncologists on treatment of elderly men with Stage IV prostate cancer

OBJECTIVES

To examine, among elderly men with incident advanced prostate cancer (PCa), their treatment, in general, and chemotherapy, in particular, in association with a posturologist medical oncologist/hematologist (PUMOH) visit. The role of specialists in the management of advanced PCa is evolving in response to positive chemotherapy trials of PCa.

METHODS

Linked Surveillance, Epidemiology, and End results and Medicare data included patients with Stage IV PCa diagnosed from 1994 to 2002 who had visited a urologist after the diagnosis and received treatment. The visits and treatment were examined, comparing patients with and without PUMOH visits.

RESULTS

Most (77%) patients received treatment of their PCa and 85% of treated patients had a subsequent visit with a urologist, of whom 91% saw the urologist first (n = 5435). Of these, 43% saw only the urologist, 41% saw a medical oncologist/hematologist, and 32% saw a radiation oncologist. Of the 5435 patients, 16% received chemotherapy and the adjusted odds of chemotherapy receipt were 7.2 times greater (95% confidence interval 6.0-8.7, P < .001) among those with a PUMOH visit. Compared with non-Hispanic whites, black Americans were less likely (adjusted odds ratio 0.53, P < .001) to receive chemotherapy, although the likelihood of a PUMOH visit was similar (adjusted odds ratio 0.86, P = .14) among the groups.

CONCLUSIONS

The results of our study have shown that nearly one quarter of men with Stage IV PCa receive no PCa treatment. Although a PUMOH visit is a significant predictor of chemotherapy receipt, many men with advanced PCa received chemotherapy without a medical oncologist/hematologist visit. Black American and elderly men were less likely to receive chemotherapy for advanced PCa.

Radiotherapy and survival in prostate cancer patients: a population-based study

PURPOSE

To investigate the association of overall and disease-specific survival with the five standard treatment modalities for prostate cancer (CaP): radical prostatectomy (RP), brachytherapy (BT), external beam radiotherapy, androgen deprivation therapy, and no treatment (NT) within 6 months after CaP diagnosis.

METHODS AND MATERIALS

The study population included 10,179 men aged 65 years and older with incident CaP diagnosed between 1999 and 2001. Using the linked Ohio Cancer Incidence Surveillance System, Medicare, and death certificate files, overall and disease-specific survival through 2005 among the five clinically accepted therapies were analyzed.

RESULTS

Disease-specific survival rates were 92.3% and 23.9% for patients with localized vs. distant disease at 7 years, respectively. Controlling for age, race, comorbidities, stage, and Gleason score, results from the Cox multiple regression models indicated that the risk of CaP-specific death was significantly reduced in patients receiving RP or BT, compared with NT. For localized disease, compared with NT, in the monotherapy cohort, RP and BT were associated with reduced hazard ratios (HR) of 0.25 and 0.45 (95% confidence intervals 0.13-0.48 and 0.23-0.87, respectively), whereas in the combination therapy cohort, HR were 0.40 (0.17-0.94) and 0.46 (0.27-0.80), respectively.

CONCLUSIONS

The present population-based study indicates that RP and BT are associated with improved survival outcomes. Further studies are warranted to improve clinical determinates in the selection of appropriate management of CaP and to improve predictive modeling for which patient subsets may benefit most from definitive therapy vs. conservative management and/or observation.

Use of androgen deprivation therapy for metastatic prostate cancer in older men

OBJECTIVE

To assess factors associated with early or delayed androgen deprivation therapy (ADT) among men diagnosed with metastatic prostate cancer, and to assess the relationship between ADT and overall survival, as there is uncertainty about the ideal timing for initiating ADT in men with metastatic prostate cancer.

PATIENTS AND METHODS

We studied a population-based cohort of American men aged >or=66 years diagnosed with metastatic prostate cancer during 1992-2002 and followed to 2003. We assessed the receipt of ADT early (4 months), or not at all, using multinomial logistic regression to identify factors associated with treatment, and Cox proportional-hazard models to assess whether treatment was associated with survival.

RESULTS

Overall, 69.5% of men received early ADT and 7.3% delayed. Adjusted rates of early ADT were lower for black than white men (58.3% vs 71.0%), and of delayed ADT were higher for black than white men (12.7% vs 6.2%). Receipt of ADT was associated with improved survival (adjusted hazard ratio 0.69, 95% confidence interval 0.66-0.73). The benefit of early treatment did not differ from delayed treatment (P = 0.58).

CONCLUSIONS

A large minority of men with metastatic prostate cancer, particularly black men, receive delayed or no ADT. Early or delayed ADT was associated with similarly prolonged survival. After controlling for patient and tumour characteristics, survival did not differ by race, and receipt of ADT did not contribute to racial differences in survival.

Neoadjuvant therapy followed by prostatectomy for clinically localized prostate cancer

The results of this assessment of the literature indicated that neoadjuvant therapy followed by prostatectomy may improve long-term outcomes for patients with high-risk localized disease. In addition, this approach provides a paradigm for evaluating the activity and mechanism of action of new agents as correlative studies are facilitated by the availability of tumor tissue before and after therapy. The authors determined that a multidisciplinary approach involving oncologists, urologists, and pathologists is critical to the success of this model. Recent and ongoing studies of neoadjuvant therapy followed by prostatectomy were reviewed.