Integrated prostate cancer centers might cause an overutilization of radiotherapy for low-risk prostate cancer: A comparison of treatment trends in the United States and Germany from 2004 to 2011

Influence of demographic change on the demand for radiotherapy using forecasted predictions for prostate cancer in Germany

PURPOSE

Demographic change will lead to an increase in age-associated cancers. The demand for primary treatment, especially oncologic therapies, is difficult to predict. This work is an attempt to project the demand for radiation therapy (RT) in 2030, taking into account demographic changes using prostate cancer (PC) as an example.

MATERIALS AND METHODS

Using the GENESIS database of the Federal Statistical Office, we retrieved demographic population projections for 2030 and retrospective demographic surveys from 1999 to 2019. Additionally, we queried incidence rates for PC in the respective age groups of 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84, and +85 years from 1999-2019 via the Federal Cancer Registry of the Robert Koch Institute. We used a regression method to determine the age-dependent correlation between the incidence of PC and the population size of the respective age group by combining the data from 1999 to 2019. This information was used to calculate the incidence rates in the age groups of the expected population for 2030 and the expected new cases of PC in 2030. Finally, we extrapolated the indications for the demand for RT based on data from the Report on Cancer Incidence in Germany from 2016.

RESULTS

Considering a population-dependent incidence rate, an increase in new cases of PC is expected. This increase is particularly evident in the age groups of 70-74 and 80-84 years. With regards to RT, the estimate indicates an overall increase of 27.4% in demand. There is also a shift in RT demands towards older patients, especially in the 80- to 84-year-old age group.

CONCLUSION

We observe an age-associated increase in primary cases of PC. This is likely to result in an increased demand for RT. The exact demand cannot be predicted. However, trends can be estimated to plan for the demand. This, though, requires a good database from cancer registries.

Online decision aid for patients with prostate cancer evaluated by 11 290 patients and 91 urologists in Germany

OBJECTIVE

To evaluate the nationwide online decision aid 'Entscheidungshilfe Prostatakrebs' (established in 2016, >11.000 users and 60 new users/week) for patients with non-metastatic prostate cancer (PCa), from the perspective of patients and urologists.

PATIENTS AND METHODS

To provide personalised information, the tool collects most of the International Consortium for Health Outcomes Measurement standard set, personal preferences, psychological features, and a validated rating of the tool. To evaluate urologists' opinions, we developed a structured two-page questionnaire. All data were collected anonymously.

RESULTS

From June 2016 to December 2020, 11 290 patients used the PCa decision aid. Their median (interquartile range [IQR]) age was 67 (61-72) years. The median (IQR) time from initial diagnosis to using the tool was 4 (3-7) weeks. In all, 87.7% of users reported high satisfaction. In a multivariable model, predictors for considering observation were higher knowledge, using the decision aid alone, lower oncological risk, normal erectile function, and respective personal preferences. Of 194 urologists, 91 (47%) had implemented the decision aid in their clinical practice. The urologists' mean (SD) satisfaction score (1 'very good'; 6 'unsatisfactory') with it was 1.45 (0.55), and 92% recommended it. Half of the urologists reported time savings.

CONCLUSION

Patients and urologists report a very high level of acceptance and satisfaction with this online tool. It offers advantages in shared decision-making and time efficiency. The usage of the decision aid might improve the adoption of active surveillance and watchful waiting when indicated.

Cancer mortality in Germany-born Americans and Germans

INTRODUCTION

Comparing cancer mortality and associated risk factors among immigrant populations in a host country to those in their country of origin reveals disparities in cancer risk, access to care, diagnosis, and disease management. This study compares cancer mortality between the German resident population and Germany-born individuals who migrated to the US.

METHODS

Cancer mortality data from 2008-2018 were derived for Germans from the World Health Organization database and for Germany-born Americans resident in four states (California, Florida, Massachusetts, and New York) from respective Departments of Vital Statistics. We calculated age-standardized mortality rates (ASMRs) using the European standard population and standardized mortality ratios (SMR) compared to the German resident population along with 95% confidence intervals (CIs).

RESULTS

Germany-born American males had lower ASMRs (253.8 per 100,000) than German resident population (325.6 per 100,000). The difference in females was modest, with ASMRs of 200.7 and 203.7 per 100,000, respectively. For all cancers, Germany-born American males had an SMR of 0.72 (95% CI: 0.70-0.74) and females 0.98 (95% CI: 0.95-1.00). Male SMRs among Germany-born Americans were significantly below one for oral cavity, stomach, colorectal, liver, lung, prostate, and kidney cancer. Among females, SMRs were below one for oral cavity, stomach, colorectal, gallbladder, breast, cervix uteri, and kidney cancer. For both sexes, SMRs were over one for bladder cancer (1.14 for males, 1.21 for females). Mortality was higher for lung cancer (SMR: 1.68), non-Hodgkin's lymphoma (1.18) and uterine cancer (1.22) among Germany-born American females compared to the German resident population.

CONCLUSION

Germany-born American males but not females showed lower cancer mortality than German resident population. Disparities may stem from variations in risk factors (e.g., smoking and alcohol use) as well as differences in screening practices and participation, cancer treatment, besides some residual potential "healthy immigrant effect".

Prostate cancer treatment in Portugal: a nationwide analysis

Different treatment options exist for localized prostate cancer. Treatments performed in high-volume hospitals are associated with better results. Our objective was to describe time trends in prostate cancer treatments in Portugal and case volume per hospital. We used the national database of diagnosis-related group of the Portuguese Central Administration of the Health System to describe the number of radical prostatectomy (RP), brachytherapy (BT) and external radiotherapy (eRT) treatments performed in all National Health System hospitals. There was a rapid increase in the annual number of RP until 2006 and then a deceleration; BT treatments augmented significantly until 2011. The utilization of eRT also increased, surpassing RP after 2010. From the 46 hospitals performing RP, only eight had a case-volume > 50 treatments/year, and from the nine hospitals performing BT, only four accomplished > 15 treatments/year. In the 11 hospitals with eRT, nine performed > 50/year. Regarding RP, there was negative correlation between the hospital volume and length of stay (r = - 0.303; p = 0.041). In the Portuguese National Health Service there was a steep increase in the number of prostate cancer treatments, and there is an ample margin for concentration of RP and BT treatments, for improvement of the hospitals case volume.

Acquired resistance to irradiation or docetaxel is not associated with cross-resistance to cisplatin in prostate cancer cell lines

PURPOSE

Platinum chemotherapy can be considered to treat metastatic castration-resistant prostate cancer (mCRPC) with features of neuroendocrine differentiation. However, platinum compounds are generally only applied after the failure of multiple prior-line treatment options. This study investigated whether acquired resistance against ionizing radiation or docetaxel chemotherapy-two commonly applied treatment modalities in prostate cancer-influences the cisplatin (CDDP) tolerance in mCRPC cell line models.

METHODS

Age-matched parental as well as radio- or docetaxel-resistant DU145 and PC-3 cell lines were treated with CDDP and their sensitivity was assessed by measurements of growth rates, viability, apoptosis, metabolic activity and colony formation ability.

RESULTS

The data suggest that docetaxel resistance does not influence CDDP tolerance in all tested docetaxel-resistant cell lines. Radio-resistance was associated with sensitization to CDDP in PC-3, but not in DU145 cells. In general, DU145 cells tolerated higher CDDP concentrations than PC-3 cells regardless of acquired resistances. Furthermore, non-age-matched treatment-naïve PC-3 cells exhibited significantly different CDDP tolerances.

CONCLUSION

Like patients, different mCRPC cell lines exhibit significant variability regarding CDDP tolerance. The presented in vitro data suggest that previous radiation treatment may be associated with a moderate sensitization to CDDP in an isogenic and age-matched setting. Therefore, previous radiotherapy or docetaxel chemotherapy might be no contraindication against initiation of platinum chemotherapy in selected mCRPC patients.

Development of Incidence and Surgical Treatment of Penile Cancer in Germany from 2006 to 2016: Potential Implications for Future Management

BACKGROUND

Penile cancer is a rare disease and surgical treatment often entails a significant impact on quality of life. The aim of this study was to analyze trends in surgical treatment patterns in Germany.

METHODS

We analyzed data from the nationwide German hospital billing database and the German cancer registry from 2006 to 2016. All penile cancer cases with penile surgery or lymph node dissection (LND) were included. We also analyzed the distribution of cases, extent of surgery, and length of hospital stay, stratified for annual caseload. The geographical distribution of centers for 2016 was presented.

RESULTS

During the investigated timespan, tumor incidences increased from 748 to 971 (p = 0.001). We identified 11,353 penile surgery cases, increasing from 886 to 1196 (p < 0.001), and 5173 cases of LND, increasing from 332 to 590 (p < 0.001). Cases of partial amputation increased from 45.8 to 53.8% (p < 0.001), while total amputation remained stable at 11.2%. Caseload in high-volume hospitals increased from 9.0 to 18.8% for penile surgery (p < 0.001) and from 0 to 13.1% for LND (p < 0.001). The increase in LND caseload was caused by an increase in inguinal LND, from 297 to 505 (p < 0.001), with increasing sentinel LND, from 14.2 to 21.9% (p = 0.098). The assessment of geographical distribution of cases in Germany revealed extensive areas without sufficient coverage by experienced centers.

CONCLUSIONS

We saw consistent increases in penile surgery and LND, with a growing number of cases in high-volume hospitals, and, accordingly, an increase in tumor incidence. The increasing use of inguinal LND and organ-preserving surgery reflect the adaptation of current guidelines; however, geographical distribution of experienced centers could be improved.

[Trends in uro-oncological surgery in Germany-comparative analyses from population-based data]

Obwohl urologische maligne Erkrankungen mit etwa 100.000 Neuerkrankungen pro Jahr eine relevante gesundheitsökonomische Aufgabe darstellen, existieren kaum Erkenntnisse über die Struktur und Entwicklung der entsprechenden tumorchirurgischen Eingriffe an den mehr als 400 urologisch-chirurgisch tätigen Kliniken in Deutschland. Somit erfassten wir mittels Datenbankabfrage der DRG-Datenbank („diagnosis related groups“) des statistischen Bundesamtes sämtliche Fälle von 5 großen tumorchirurgischen Eingriffen in Deutschland (Prostatektomie, Zystektomie, Nierentumoroperation, retroperitoneale Lymphadenektomie, penischirurgische Eingriffe) von 2006 bis 2013 (bzw. 2016) und untersuchten die Einflüsse von technischen Neuerungen sowie Leitlinienänderungen auf die Entwicklungen der Fallzahlen. Zudem analysierten wir die Zusammenhänge zwischen jährlicher Fallzahl und perioperativem Ergebnis. Die Ergebnisse zeigten eine deutliche Korrelation zwischen Fallzahlvolumen (und damit Expertise) einer Klinik und einem verbesserten perioperativen Ergebnis. Dennoch existiert kaum Tendenz zur Zentralisierung bei diesen uroonkologischen Eingriffen. Die Fallzahlentwicklungen scheinen vielmehr vom Werbeeffekt durch technische Innovationen oder auch vom regionalen Bezug der Patienten zu einer bestimmten Klinik abhängig zu sein. Zentral gesteuerte Versuche mittels Einführung von Mindestfallzahlen oder der freiwilligen Zertifizierung von Zentren hatten in der Vergangenheit nur geringen Einfluss auf die Fallzahlverteilungen.

[On the practice of therapy decision in locally limited prostate cancer: surgery vs. radiation-who benefits? : Allocation and results of a monocentric, cumulative long-term study]

AIM

The goal of this two-armed observational study was to map the clinical therapy effectiveness of radical prostatovesiculectomy (RPVE) and external beam radiation therapy (EBRT) in locally limited prostate cancer (PCA) in direct comparison over 20 years under clinical conditions. Retrospectively, the various variables and predictors for the individual therapy decision were identified, and the preference was to compared with studies on survival and recurrence characteristics. The presentation of toxicity was not the focus of this work.

METHODOLOGY

In all, 743 patients from a single center were enrolled according to biopsy/staging chronologically in the sequence of the initial consultation after clarification and informed consent: 494 patients were in the RPVE arm and 249 patients in the EBRT arm. We used retrospective data analysis with univariate and multivariate comparisons in the alternative therapy arms. Multivariate logical regression models were developed to objectify the allocation process. Univariate processing of survival analyses, the comparison of tumor- and comorbidity-specific mortality rates was co-founded.

RESULTS

Predictive variables for RPVE vs. EBRT therapy decision are significantly age, Gleason score, D'Amico index, Charlson index, prostate-specific antigen (PSA), and prostate volume. There was no significance level for the biopsy score. The age gap was in the median 67 (RPVE) and 73 (EBRT) years. Overall survival (n = 734, 20 years, all risks) in the RPVE arm was 56.8% (95% confidence interval [CI] 45.1-67.0%) and in the EBRT arm 19.2% (95%CI 9.2-31.8%). Comorbid risk was highly significantly (p < 0.0001) different (27.1% [95%CI 18.0-36.1%] in the RPVE arm, and 60.4% [95%CI 47.3-73.5%] in the EBRT arm). The risk of tumor-specific death at 16.2% (95%CI 8.1-24.4%) after RPVE and 20.5% (95%CI 11.7-29.3%) after EBRT was not significantly different (p = 0.2122, overlapping 95%CI). After stratification, a clear advantage can be demonstrated for the high-risk tumors after allocation to the RPVE arm.

CONCLUSIONS

The complexity of the predictive variables of the PCA further complicates the individual therapy decision. According to our data, the higher D'Amico score, the rather low Charlson index, a high Gleason score and a higher organ volume speak for a valid therapy for RPVE.

Effect of Radiotherapy in Addition to Surgery in Early Stage Endometrial Cancer: A Population-Based Study

BACKGROUND

The role of radiotherapy in the management of early (FIGO I) endometrial cancer is controversial with limited availability of prospective data from randomized trials.

METHODS

German Epidemiologic Cancer Registries provided by the Robert Koch Institute. We considered FIGO I cases with recorded operative treatment (n = 12,718, 2000-2017). We computed hazard ratios (HR) from relative survival models in relation to the mortality of the general population with 95% confidence intervals (CI). Multivariate models were adjusted for age, stage (IA vs. IB), grading, and chemotherapy. Radiotherapy included external radiotherapy and brachytherapy.

RESULTS

Cases with a favorable risk profile (FIGO IA, G1/G2) had a slightly lower survival rate, relative to the general population (FIGO IA: 0.9, G1: 0.91). The proportion of FIGO IA cases was lower in the radiotherapy group (52.6%) vs. cases without radiotherapy (78.6%). Additional treatment with radiotherapy was beneficial in FIGO IB (HR = 0.74) and all histopathological grades, but not FIGO IA cases (HR = 0.93) cases. Compared to IA tumors, IB cases had a HR of 1.51 (95% CI: 1.34-1.7).

CONCLUSIONS

Radiotherapy in addition to surgery is beneficial for patients in a FIGO IB stage. Further studies need to address the impact of new techniques and risk assessment.

Predictors of the regional variation of prostatectomy or radiotherapy: evidence from German cancer registries

OBJECTIVE

To assess the association of public health parameters with the regional variation in the initial treatment for prostate cancer.

METHODS

We used data from German epidemiologic cancer registries for the years 2009-2013. Presence of a certified cancer center, a radiotherapy and/or urology institution, the district-specific GDP, and population density were used as predictors. Patients with indication for adjuvant treatment were excluded (T3b). Only districts with defined quality criteria were eligible. We used general linear mixed models (equivalent to logistic regression) with a covariance matrix weighted by the Euclidean distances between districts. Models were adjusted for age, grading, and TNM stage. We performed sensitivity analyses by imputing missing data with multiple imputation and considering extreme case scenarios. We applied inverse probability weighting to account for missing values.

RESULTS

When radiotherapy/surgery is compared to neither treatment, the probability for the latter was higher in East than in West Germany (OR 1.7, 95% CI 1.43-2.02). The same was true for districts with both, a radiotherapy and urologic treatment facility (OR 1.43, 1.19-1.72). Analyzing radiotherapy vs. surgery, the probability for prostatectomy was inversely associated with the presence of a radiotherapy unit when compared to districts with neither treatment facility (OR 0.52, 95% CI 0.38-0.73). Patients treated in East Germany were more likely to receive a surgical treatment (OR 1.34, 95% CI 1.08-1.66). Sensitivity analyses revealed no relevant change of effect estimates.

CONCLUSION

Treatment differs between East and West Germany and is associated with the presence of a radiotherapy or urology clinic.

Benefit from surgery with additional radiotherapy in N1 head and neck cancer at the time of IMRT: A population-based study on recent developments

BACKGROUND

Currently, the role of adjuvant irradiation in head and neck cancer (HNC) patients with N1-lymph node status is not clarified.

OBJECTIVES

To assess the population-based effect of recent developments in radiotherapy such as intensity-modulated radiotherapy (IMRT) in relation to overall survival (OS) together with surgery in N1 HNC patients.

MATERIALS AND METHODS

We used 9,318 HNC cases with pT1/2 N0/1 disease from German cancer registries. Time of diagnosis ranged from January 2000 to December 2014, which we divided into three periods: (low [LIA] vs intermediate [IA] vs high [HIA] IMRT availability period) based on usage of IMRT in Germany. For each period, we examined a possible association between treatment (surgery vs. surgery and radiotherapy) in terms of OS. Statistical analyses included Kaplan-Meier and multivariate Cox regression (models adjusted for HPV-related cancer site).

RESULTS

Temporal analysis revealed increasing usage of IMRT in Germany. In patients with N1 tumours, a comparison of patients treated with and without radiotherapy during the HIA period showed a superiority of the combined treatment as opposed to surgery alone (HR 0.54, 95%CI: 0.35-0.85, p = 0.003). The survival analyses related to treatments in terms of period underlined the superiority of surgery plus radiotherapy between periods IA and HIA (p = 0.03).

CONCLUSION

The advent of IMRT, additional radiotherapy may present a survival advantage in patients with N1 HNC when combined with surgery.

Early Mortality of Prostatectomy vs. Radiotherapy as a Primary Treatment for Prostate Cancer: A Population-Based Study From the United States and East Germany

Objective: To assess the extent of early mortality and its temporal course after prostatectomy and radiotherapy in the general population.

Methods: Data from the Surveillance, Epidemiology, and End Results (SEER) database and East German epidemiologic cancer registries were used for the years 2005–2013. Metastasized cases were excluded. Analyzing overall mortality, year-specific Cox regression models were used after adjusting for age (including age squared), risk stage, and grading. To estimate temporal hazards, we computed year-specific conditional hazards for surgery and radiotherapy after propensity-score matching and applied piecewise proportional hazard models.

Results: In German and US populations, we observed higher initial 3-month mortality odds for prostatectomy (USA: 9.4, 95% CI: 7.8–11.2; Germany: 9.1, 95% CI: 5.1–16.2) approaching the null effect value not before 24-months (estimated annual mean 36-months in US data) after diagnosis. During the observational period, we observed a constant hazard ratio for the 24-month mortality in the US population (2005: 1.7, 95% CI: 1.5–1.9; 2013: 1.9, 95% CI: 1.6–2.2) comparing surgery and radiotherapy. The same was true in the German cohort (2005: 1.4, 95% CI: 0.9–2.1; 2013: 3.3, 95% CI: 2.2–5.1). Considering low-risk cases, the adverse surgery effect appeared stronger.

Conclusion: There is strong evidence from two independent populations of a considerably higher early to midterm mortality after prostatectomy compared to radiotherapy extending the time of early mortality considered by previous studies up to 36-months.

Centralization tendencies of retroperitoneal lymph node dissection for testicular cancer in Germany? A total population-based analysis from 2006 to 2015

INTRODUCTION

Retroperitoneal lymph node dissection (RPLND) is a standard treatment in the management of metastatic testicular cancer. Due to modified treatment algorithms, it is becoming less frequent.

MATERIALS AND METHODS

We analyzed data from the nationwide German hospital billing database covering 2006-2015. Cases with a testicular cancer diagnosis combined with RPLND were included. We assessed the length of hospital stay (LOS), blood transfusion, and in-hospital mortality stratified for surgical approach, hospital characteristics, and annual caseload. Annual hospital caseload categories were defined as low (< 4), medium (4-10), and high (> 10). We supplemented tumor incidence and staging data from the German cancer registry (60% of population).

RESULTS

4926 cases were included with decreasing annual caseload numbers from 623 in 2006 to 382 in 2015. The incidence of testicular cancer and higher tumor stages remained stable. High-volume hospitals performed 19.4%, medium-volume hospitals 43.7%, and low-volume hospitals 36.8% RPLNDs. Low- abd medium-volume hospitals declined, while high-volume hospitals (n = 5) maintained their annual caseload. Overall in-hospital mortality was 0.47%. Blood transfusion rates were higher in high-volume centers assumedly due to selection of more complex cases. However, high-volume hospitals showed a shorter LOS with 10.5 vs. 11.2 (medium volume), and 12.7 days (low volume).

CONCLUSION

Total numbers of RPLND have declined from 2006 to 2015, while tumor incidences and stages remained fairly stable. Constant reduction of indication in guidelines contributes to this finding. High-volume hospitals achieve shorter hospital stays in spite of assumedly more complex and extensive cases. There is a modest trend towards unregulated centralization.

Quality indicators of clinical cancer care for prostate cancer: a population-based study in southern Switzerland

Background

Quality of cancer care (QoCC) has become an important item for providers, regulators and purchasers of care worldwide. Aim of this study is to present the results of some evidence-based quality indicators (QI) for prostate cancer (PC) at the population-based level and to compare the outcomes with data available in the literature.

Methods

The study included all PC diagnosed on a three years period analysis (01.01.2011–31.12.2013) in the population of Canton Ticino (Southern Switzerland) extracted from the Ticino Cancer Registry database. 13 QI, approved through the validated Delphi methodology, were calculated using the “available case” approach: 2 for diagnosis, 4 for pathology, 6 for treatment and 1 for outcome. The selection of the computed QI was based on the availability of medical documentation. QI are presented as proportion (%) with the corresponding 95% confidence interval.

Results

700 PC were detected during the three-year period 2011–2013: 78.3% of them were diagnosed through a prostatic biopsy and for 72.5% 8 or more biopsy cores were taken. 46.5% of the low risk PC patients underwent active surveillance, while 69.2% of high risk PC underwent a radical treatment (radical prostatectomy, radiotherapy or brachytherapy) and 73.5% of patients with metastatic PC were treated with hormonal therapy. The overall 30-day postoperative mortality was 0.5%.

Conclusions

Results emerging from this study on the QoCC for PC in Canton Ticino are encouraging: the choice of treatment modalities seems to respect the international guidelines and our results are comparable to the scarce number of available international studies. Additional national and international standardisation of the QI and further QI population-based studies are needed in order to get a real picture of the PC diagnostic-therapeutic process progress through the definition of thresholds of minimal standard of care.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4604-2) contains supplementary material, which is available to authorized users.

Toward a comprehensive cancer registration in Germany

This article presents the current status of the implementation of clinical cancer registration across all German federal states that started in 2013 and that is basis for setting up comprehensive clinical and population-based cancer registries (CRs). A nationwide definition of relevant cancers, a common model of passive registration, a standard basic set of data items as well as a sustainable funding are prerequisites for a standardized collection of cancer data in Germany. For the collected information, the tools and methods used for data collection and processing, for statistical analyses and reporting, the potential synergies of a comprehensive CR implementing the tasks of both a clinical CR and a population-based CR become evident. Many different tasks of clinical and population-based CRs have already been implemented in Germany. This includes usage of individual patient data for quality assurance and the certification of cancer centers or comparative analyses on the adherence to guideline recommendations. CRs further provided unselected data on the cancer burden in the underlying populations and actively contribute in a variety of ways to many collaborative research projects on cancer etiology, the effectiveness of screening programs or cancer care, or provide patient or outcome data for clinical or population-based studies. Although many tasks of clinical and population-based CRs have already been implemented, a number of great efforts still lay ahead. Major challenges include the harmonization of data collection, the development of required standards and methods for data processing and usage, but first and foremost, the collection of complete and valid data for the different tasks of comprehensive CRs.

A retrospective analysis of Victorian and South Australian clinical registries for prostate cancer: trends in clinical presentation and management of the disease

BACKGROUND

Prostate cancer (PCa) is the most commonly diagnosed malignancy reported to Australian cancer registries with numerous studies from individual registries summarizing diagnostic and treatment characteristics. The aim of this study was to describe annual trends in clinical and treatment characteristics, and changes in surveillance practice within a large combined cohort of men with PCa in South Australia (SA) and Victoria, Australia in 2008-2013.

METHODS

Common data items from clinical registries in SA and Victoria were merged to develop a cross-jurisdictional dataset consisting of 13,598 men with PCa. Frequencies were used to describe these variables using the National Comprehensive Cancer Network risk of disease progression categories in 10 year age groups. A logistic regression analysis was performed to assess the impact of a number of factors (both individually and together) on the likelihood of men receiving no active treatment within twelve months of the diagnosis (i.e. managed with active surveillance/watchful waiting).

RESULTS

Trend analysis showed that over time: (1) men in SA and Victoria are being diagnosed at older age in 2013, 66.1 (SD = 9.7) years compared to 2009 (64.5 (SD = 9.7)); (2) diagnostic methods and characteristics have changed with time; and (3) types of the treatments have changed, with more men having no active treatment. The majority of men were diagnosed with Prostate-Specific Antigen (PSA) <10 ng/mL (66 %) and Grade Group < 4 (65 %). Nearly seventy percent received radical treatment within 12 months of diagnosis, while ~20 % had no active treatment. In 14 % of cases treatment was not recorded or had not commenced. Having no active treatment was strongly associated older age, lower PSA and lower Grade Group at diagnosis, and in 2013 it was offered more frequently (more than 3 times) than in 2009 (OR = 2.63, 95 % CI: 2.16-3.22).

CONCLUSIONS

Findings of this study provide the first cross-jurisdictional description of PCa characteristics and management in Australia. These findings will provide benchmarking for ongoing monitoring and feedback of disease management and outcomes of PCa through the Prostate Cancer Outcomes Registry-Australia New Zealand to improve evidence-based practice.

Comparison of prostate cancer survival in Germany and the USA: can differences be attributed to differences in stage distributions?

OBJECTIVES

To better understand the influence of prostate-specific antigen (PSA) screening and other health system determinants on prognosis of prostate cancer, up-to-date relative survival (RS), stage distributions, and trends in survival and incidence in Germany were evaluated and compared with the United States of America (USA).

PATIENTS AND METHODS

Incidence and mortality rates for Germany and the USA for the period 1999-2010 were obtained from the Centre for Cancer Registry Data at the Robert Koch Institute and the USA Surveillance Epidemiology and End Results (SEER) database. For analyses on stage and survival, data from 12 population-based cancer registries in Germany and from the SEER-13 database were analysed. Patients (aged ≥ 15 years) diagnosed with prostate cancer (1997-2010) and mortality follow-up to December 2010 were included. The 5- and 10-year RS and survival trends (2002-2010) were calculated using standard and model-based period analysis.

RESULTS

Between 1999 and 2010, prostate cancer incidence decreased in the USA but increased in Germany. Nevertheless, incidence remained higher in the USA throughout the study period (99.8 vs 76.0 per 100,000 in 2010). The proportion of localised disease significantly increased from 51.9% (1998-2000) to 69.6% (2007-2010) in Germany and from 80.5% (1998-2000) to 82.6% (2007-2010) in the USA. Mortality slightly decreased in both countries (1999-2010). Overall, 5- and 10-year RS was lower in Germany (93.3%; 90.7%) than in the USA (99.4%; 99.6%) but comparable after adjustment for stage. The same patterns were seen in age-specific analyses. Improvements seen in prostate cancer survival between 2002-2004 and 2008-2010 (5-year RS: 87.4% and 91.2%; +3.8% units) in Germany disappeared after adjustment for stage (P = 0.8).

CONCLUSION

The survival increase in Germany and the survival advantage in the USA might be explained by differences in incidence and stage distributions over time and across countries. Effects of early detection or a lead-time bias due to the more widespread utilisation and earlier introduction of PSA testing in the USA are likely to explain the observed patterns.

Active surveillance in Canadian men with low-grade prostate cancer

BACKGROUND

Recent guidelines recommend against routine screening for prostate cancer, partly because of the risks associated with overtreatment of clinically indolent tumours. We aimed to determine the proportion of patients whose low-grade prostate cancer was managed by active surveillance instead of immediate treatment.

METHODS

We reviewed data for patients who were referred to the Ottawa regional Prostate Cancer Assessment Clinic with abnormal results for prostate-specific antigen (PSA) or prostate examination between Apr. 1, 2008, and Jan. 31, 2013. Patients with subsequent biopsy-proven low-grade (Gleason score 6) cancer were included. Active surveillance was defined a priori as monitoring by means of PSA, digital rectal examination and repeat biopsies, with the potential for curative-intent treatment in the event of disease progression.

RESULTS

Of 477 patients with low-grade cancer, active surveillance was used for 210 (44.0%), and the annual proportion increased from 32% (11/34) in 2008 to 67% (20/30) in 2013. Factors associated with immediate treatment were palpable tumour, PSA density above 0.2 ng/mL(2) and more than 2 positive biopsy cores. Factors associated with surveillance were age over 70 years and higher Charlson comorbidity index. Of 173 men who received immediate surgical treatment, 103 (59.5%) had higher-grade or advanced-stage disease on final pathologic examination. Of the 210 men with active surveillance, 62 (29.5%) received treatment within a median of 1.3 years, most commonly (52 [84%]) because of upgrading of disease on the basis of surveillance biopsy.

INTERPRETATION

Active surveillance has become the most common management strategy for men with low-grade prostate cancer at our regional diagnostic centre. Factors associated with immediate treatment reflected those that increase the risk of higher-grade tumours.