USE OF IMAGING TESTS FOR STAGING NEWLY DIAGNOSED PROSTATE CANCER: TRENDS FROM THE CAPSURE DATABASE

MUSIC: patterns of care in the radiographic staging of men with newly diagnosed low risk prostate cancer

PURPOSE

MUSIC is a statewide consortium of 42 urology practices that aims to improve the quality of prostate cancer care in Michigan. As an initial priority, we examined patterns of care in the radiographic staging of men with newly diagnosed prostate cancer. We determined whether collaborative-wide data review and performance feedback would decrease the imaging rate in men with low risk prostate cancer.

MATERIALS AND METHODS

Practices submitted standardized data, including the use and results of staging computerized tomography and bone scan, to a web based clinical registry of all men with newly diagnosed prostate cancer. We identified all patients with low risk prostate cancer and compared imaging use patterns before and after practice level performance feedback and guideline review, which were provided at collaborative-wide meetings.

RESULTS

In MUSIC 813 patients were newly diagnosed with low risk prostate cancer during the 19-month study period. Of 410 patients diagnosed in the prefeedback period (phase I) 15 (3.7%) and 21 (5.2%) underwent bone scan and computerized tomography, respectively. Of 403 patients diagnosed after feedback (phase II) radiographic staging was done in 5 men (1.3%) with bone scan and in 13 (3.2%) with computerized tomography (p = 0.03 and 0.17, respectively).

CONCLUSIONS

The overall rate of radiographic staging in men with newly diagnosed low risk prostate cancer was appropriately low. The imaging rate decreased even further after collaborative education and performance feedback. MUSIC appears to be a successful tool for quality improvement, affecting practice patterns and increasing efficiency of care.

Prostate cancer imaging trends after a nationwide effort to discourage inappropriate prostate cancer imaging

BACKGROUND

Reducing inappropriate use of imaging to stage incident prostate cancer is a challenging problem highlighted recently as a Physician Quality Reporting System quality measure and by the American Society of Clinical Oncology and the American Urological Association in the Choosing Wisely campaign. Since 2000, the National Prostate Cancer Register (NPCR) of Sweden has led an effort to decrease national rates of inappropriate prostate cancer imaging by disseminating utilization data along with the latest imaging guidelines to urologists in Sweden. We sought to determine the temporal and regional effects of this effort on prostate cancer imaging rates.

METHODS

We performed a retrospective cohort study among men diagnosed with prostate cancer from the NPCR from 1998 to 2009 (n = 99 879). We analyzed imaging use over time stratified by clinical risk category (low, intermediate, high) and geographic region. Generalized linear models with a logit link were used to test for time trend.

RESULTS

Thirty-six percent of men underwent imaging within 6 months of prostate cancer diagnosis. Overall, imaging use decreased over time, particularly in the low-risk category, among whom the imaging rate decreased from 45% to 3% (P < .001), but also in the high-risk category, among whom the rate decreased from 63% to 47% (P < .001). Despite substantial regional variation, all regions experienced clinically and statistically (P < .001) significant decreases in prostate cancer imaging.

CONCLUSIONS

A Swedish effort to provide data on prostate cancer imaging use and imaging guidelines to clinicians was associated with a reduction in inappropriate imaging over a 10-year period, as well as slightly decreased appropriate imaging in high-risk patients. These results may inform current efforts to promote guideline-concordant imaging in the United States and internationally.

Predictors of bone metastasis in pre-treatment staging of asymptomatic treatment-naïve patients with prostate cancer

BACKGROUND

There is no general consensus on the optimal criteria for the application of bone scintigraphy in screening of bone metastasis in patients with prostate cancer. Our study was conducted to assess the value of bone scan for pre-treatment staging of asymptomatic treatment-naïve patients with prostate cancer.

METHODS

A total of 203 consecutive asymptomatic and treatment-naïve patients with prostate cancer (age: 67.6±6.4 years) who were referred to our department for whole body bone scintigraphy were enrolled in the study. Three hours after intravenous injection of 20mCi (99m)Tc-MDP, all patients underwent whole body bone scanning using a single head gamma camera. The planar images were supplemented with SPECT as needed for questionable abnormalities or those having uncertain location on planar images.

RESULTS

The mean serum PSA levels, serum alkaline phosphatase (ALP) and Gleason score (GS) were 42.41±37.1ng/ml, 223.9±129.9IU/L and 6.7±1.1, respectively. A total of 55 cases (27.1%) out of 203 patients had bone metastases. The univariate analysis showed that serum PSA levels, GS and ALP were all significant predictors of bone metastases. However, only serum PSA and ALP levels were found to be independent predictors of bone metastasis in the multivariate logistic regression analysis. The combination of PSA and ALP (in which patients with either elevated PSA [>20ng/ml] or elevated ALP were considered as positive) had the best screening value, with 98.2% sensitivity and 48.6% specificity.

CONCLUSION

Serum ALP screening can be employed as a tool to detect the subgroup of patients who are at high risk of bone metastases, while having a PSA of <20ng/ml. The combination of PSA and ALP can be used to improve predictability of bone metastasis in newly diagnosed patients with prostate cancer, without affecting staging accuracy.

Appropriate and inappropriate imaging rates for prostate cancer go hand in hand by region, as if set by thermostat

Policy makers interested in containing health care costs are targeting regional variation in utilization, including the use of advanced imaging. However, bluntly decreasing utilization among the highest-utilization regions may have negative consequences. In a cross-sectional study of prostate cancer patients from 2004 to 2005, we found that regions with lower rates of inappropriate imaging also had lower rates of appropriate imaging. Similarly, regions with higher overall imaging rates tended to have not only higher rates of inappropriate imaging, but also higher rates of appropriate imaging. In fact, men with high-risk prostate cancer were more likely to receive appropriate imaging if they resided in areas with higher rates of inappropriate imaging. This "thermostat model" of regional health care utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients. Health care organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.

The population level prevalence and correlates of appropriate and inappropriate imaging to stage incident prostate cancer in the medicare population

PURPOSE

According to guidelines most men with incident prostate cancer do not require staging imaging. We determined the population level prevalence and correlates of appropriate and inappropriate imaging in this cohort.

MATERIALS AND METHODS

We performed a cross-sectional study of men 66 to 85 years old who were diagnosed with prostate cancer in 2004 and 2005 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. Low risk (no prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or clinical stage greater than T2) and high risk (1 or more of those features) groups were formed. Inappropriate imaging was defined as any imaging for men at low risk and appropriate imaging was defined as bone scan for men at high risk as well as pelvic imaging as appropriate. Logistic regression modeled imaging in each group.

RESULTS

Of 18,491 men at low risk 45% received inappropriate imaging while only 66% of 10,562 at high risk received appropriate imaging. For patients at low risk inappropriate imaging was associated with increasing clinical stage (T2 vs T1 OR 1.35, 95% CI 1.27-1.44), higher Gleason score (7 vs less than 7 OR 1.80, 95% CI 1.69-1.92), increasing age and comorbidity as well as decreasing education. Appropriate imaging for men at high risk was associated with lower stage (T4, T3 and T2 vs T1 OR 0.63, 95% CI 0.48-0.82, OR 0.67, 95% CI 0.60-0.80 and OR 0.87, 95% CI 0.80-0.86) and with higher Gleason score (greater than 8 and 7 vs less than 7 OR 2.18, 95% CI 1.92-2.48 and 1.51, 95% CI 1.35-1.70, respectively) as well as with younger age, white race, higher income, lower stage and more comorbidity.

CONCLUSIONS

We found poor adherence to imaging guidelines for men with incident prostate cancer. Understanding the patterns by which clinicians use imaging for prostate cancer should guide educational efforts as well as research to suggest evidence-based guideline improvements.

Bone scan overuse in staging of prostate cancer: an analysis of a Veterans Affairs cohort

OBJECTIVES

To determine the use and subsequent yield of bone scan imaging in a contemporary Veterans Affairs (VA) cohort of men with prostate cancer. With contemporary widespread prostate-specific antigen (PSA) screening, more patients are being diagnosed with low- and intermediate-risk prostate cancer, reducing the need and yield of bone scan imaging.

METHODS

We retrospectively reviewed the charts of 1598 men diagnosed with prostate cancer from 1998 to 2004 at the Greater Los Angeles and Long Beach VA Medical Centers. We used univariate and multivariate analyses to measure the association between patient (age, race, and comorbidities) and tumor (PSA, clinical stage, Gleason grade) characteristics with bone scan use and subsequent positivity. We conducted the analysis for scans for the entire cohort and those with low and high risk of metastatic disease.

RESULTS

Of 519 men with low-risk disease, 132 (25%) underwent bone scan imaging, none with positive findings. On multivariate analysis for the entire cohort, younger age, Long Beach VA site, increasing PSA level (≥10 ng/mL), clinical stage (cT2 or greater), and Gleason score (≥7) were all positively associated with bone scan use; however, only PSA level ≥20 ng/mL, clinical stage cT3 or greater, and Gleason score ≥4 + 3 corresponded with positivity. A bone scan positivity rate of ≥10% was limited to men with clinical stage cT3 or greater, Gleason score of ≥8, or PSA level of ≥20 ng/mL.

CONCLUSIONS

Although decreasing in incidence with time, our results demonstrate extensive overuse of bone scan imaging among VA patients with low-risk prostate cancer. These patterns of overuse for men with low-risk cancer, yielding no positive findings, result in unnecessary patient anxiety and significant economic waste for the VA Healthcare System.

CT, MRI and ultrasound scanning rates: evaluation of cancer diagnosis, staging and surveillance in Ontario

OBJECTIVE

To examine practice patterns and rates of computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasound (AUS) during staging, treatment and surveillance for cancer patients.

METHODS

Using Ontario Health Insurance Plan billing data linked to the Ontario Cancer Registry, we determined rates of CT, MRI, and AUS by body site for breast, colorectal, lung, lymphoma, and prostate cancer, from 1998 to 2002. Rates of scans were additionally examined by region of patient residence and time from cancer diagnosis.

RESULTS

The frequency of imaging increased in nearly all scans and tumors over the study period. Rates of peri-diagnosis scans varied substantially by region, ranging from 1.7-fold variation (CT for lung cancer) to 50-fold variation (MRI for breast cancer). For breast cancer, there is possible over-utilization of CT, but overall rates of scanning appear reasonable for the other four cancers.

CONCLUSIONS

Considerable regional variation in imaging rates suggests utilization guidelines should be developed or knowledge transfer initiatives are needed to improve compliance to existing guidelines. In breast cancer, there appears to be over-utilization of imaging. Further studies are necessary to determine utilization for each stage, the reason scans were obtained, and the impact of scans on patient outcomes.

Decrease in Racial Disparities in the Staging Evaluation for Prostate Cancer After Publication of Staging Guidelines

PURPOSE

We compared how men with incident prostate cancer were staged before and after the 1995 publication of National Comprehensive Cancer Network, American Urological Association and American College of Radiology staging guidelines, and determined whether there were racial differences in the staging evaluation.

MATERIALS AND METHODS

We performed a retrospective cohort study of the use of bone scan and pelvic imaging (pelvic computerized tomography or magnetic resonance imaging) in 96,986 men with incident prostate cancer from 1991 to 1994 compared to 1995 to 1999 from Surveillance, Epidemiology and End Results-Medicare linked data files.

RESULTS

During 1991 to 1994 bone scan was done in 83.1% and 73.7% of men who would and would not have met guideline criteria for staging, respectively. From 1995 to 1999 bone scan use decreased slightly in men who met guideline criteria (74.4%) but it decreased substantially in men who did not meet guideline criteria (55.2%). Between 1991 to 1994 and 1995 to 1999 rates of pelvic imaging increased for men who did and decreased for men who did not meet guideline criteria for staging (45.5% to 57.2% and 48.4% to 41.5%, respectively). On multivariate analysis in men who did not meet guideline criteria there was no change in the association between the use of staging tests and race from 1991 to 1994, to 1995 to 1999. However, of men who met guideline criteria for staging black men were less likely to undergo bone scan and less likely to undergo pelvic imaging than white men diagnosed in 1991 to 1994 but this racial difference was not seen during 1995 to 1999.

CONCLUSIONS

Using a population based cohort this study reveals a decrease in racial disparity and an increase in evidence based use of staging tests in men with incident prostate cancer in the period after the publication of National Comprehensive Cancer Network, American Urological Association and American College of Radiology guidelines.

Patterns of practice in the United States: insights from CaPSURE on prostate cancer management

The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) is a national disease registry of more than 10,000 patients with prostate cancer treated at 31 primarily community-based sites across the country. The database tracks oncologic and health-related quality-of-life outcomes. Because the urologists participating in the project treat according to their usual practices, CaPSURE facilitates the study of trends in disease-management strategies, offering a reflection of "real world" practice patterns. This review highlights key studies during the past several years that document downward risk migration, validates widely used prognostic nomograms, establishes prostate-specific antigen doubling time as a surrogate endpoint for disease-specific mortality, assesses the impact of treatment on patient-reported quality of life, and presents national trends in imaging test use and primary treatment strategies for localized disease.

Prostate Cancer: Gadolinium-enhanced MR Imaging at 3 Weeks Compared with Needle Biopsy at 6 Months after Cryoablation

PURPOSE

To determine if nonenhancing tissue on gadolinium-enhanced magnetic resonance (MR) images obtained 3 weeks after cryoablation of the prostate helps reliably and accurately predict nonviable cryoablated tissue at 6-month biopsy.

MATERIALS AND METHODS

Fifty-four consecutive patients with prostate cancer who underwent cryoablation were followed up prospectively. Fifty-one underwent gadolinium-enhanced MR imaging at 3 weeks (three had gadolinium allergy); 49, biopsy at 6 months (three refused and two had other primary malignancies); and all, prostate-specific antigen (PSA) tests at 6 weeks, 3 months, and every 3 months thereafter. MR images were evaluated and scored according to the degree of signal void and were correlated with the 6-month biopsy reports and, to a lesser degree, PSA levels. The biopsy reports were examined for the presence or absence of cancerous tissue, viable tissue, and nonviable tissue. A one-way analysis of variance was used for statistical and regression analyses.

RESULTS

The correlation of MR imaging scores with PSA levels and MR imaging scores with biopsy findings resulted in P values of.337 and.780, respectively. A slight statistically significant trend existed for the relation of biopsy results with PSA levels, with a P value of.041, which was expected.

CONCLUSION

Findings of postoperative gadolinium-enhanced MR imaging are not predictive of 6-month biopsy results or follow-up PSA levels.

Value of prostate-specific antigen in the staging of Taiwanese patients with newly diagnosed prostate cancer

Records of 71 patients diagnosed with prostate cancer were reviewed retrospectively regarding clinical stage, prostate-specific antigen (PSA), Gleason score, CT scan of pelvis, bone scan, and pelvic lymph node dissection. Fourteen patients had pelvic lymphadenopathy based on the CT scan. Of these, no patient had a PSA level <4 ng/mL, 1 patient had a PSA level between 4 and 10 ng/mL, and 3 had a PSA level between 10 and 20 ng/mL. Twelve of 13 patients with positive bone scan results had a PSA level >20 ng/mL, and 1 patient had a PSA level between 10 and 20 ng/mL. PSA can be cost-effective in selecting and identifying appropriate staging for patients with newly diagnosed prostate cancer. CT scans are not indicated in men with clinical localized prostate cancer when PSA levels are < or =10 ng/mL. Bone scan is not required for staging asymptomatic men with PSA levels of < or =20 ng/mL. Pelvic lymphadenectomy for localized prostate cancer may not be necessary if PSA levels is < or =20 ng/mL and Gleason score is < or =5.

BASELINE STAGING OF NEWLY DIAGNOSED PROSTATE CANCER: A SUMMARY OF THE LITERATURE

PURPOSE

Staging for prostate cancer often includes bone scanning and computerized tomography (CT). We systematically reviewed the published evidence for these tests.

MATERIALS AND METHODS

We searched MEDLINE for articles on these investigations in newly diagnosed cases of prostate cancer. Data were pooled based on prostate specific antigen (PSA), grade and tumor stage.

RESULTS

Among 23 studies examining the role of bone scan metastases were detected in 2.3%, 5.3% and 16.2% of patients with PSA levels less than 10, 10.1 to 19.9 and 20 to 49.9 ng/ml, respectively. Scanning detected metastases in 6.4% of men with organ confined cancer and 49.5% with locally advanced disease. Detection rates were 5.6% and 29.9% for Gleason scores 7 or less and 8 or greater, respectively. Among 25 studies CT documented lymphadenopathy in 0 and 1.1% of patients with PSA less than 20 and 20 ng/ml or greater, respectively. CT detection rate was 0.7% and 19.6% in patients with localized and locally advanced disease, respectively. Detection rates in patients with Gleason scores 7 or less and 8 or greater were 1.2% and 12.5%, respectively. These risks were typically much greater on pathological evaluation.

CONCLUSIONS

Patients with low risk prostate cancer are unlikely to have metastatic disease documented by bone scan or CT. Therefore, these investigations should not be standard practice. However, patients with PSA 20 ng/ml or greater, locally advanced disease, or Gleason score 8 or greater are at higher risk for bone metastases and should be considered for bone scan. CT may be useful in patients with locally advanced disease or Gleason score 8 or greater but appears not to be of benefit in patients with increased PSA alone.

THE CONTEMPORARY MANAGEMENT OF PROSTATE CANCER IN THE UNITED STATES: LESSONS FROM THE CANCER OF THE PROSTATE STRATEGIC UROLOGIC RESEARCH ENDEAVOR (CAPSURE), A NATIONAL DISEASE REGISTRY

PURPOSE

The epidemiology and treatment of prostate cancer have changed dramatically in the prostate specific antigen era. A large disease registry facilitates the longitudinal observation of trends in disease presentation, management and outcomes.

MATERIALS AND METHODS

The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) is a national disease registry of more than 10000 men with prostate cancer accrued at 31 primarily community based sites across the United States. Demographic, clinical, quality of life and resource use variables are collected on each patient. We reviewed key findings from the data base in the last 8 years in the areas of disease management trends, and oncological and quality of life outcomes.

RESULTS

Prostate cancer is increasingly diagnosed with low risk clinical characteristics. With time patients have become less likely to receive pretreatment imaging tests, less likely to pursue watchful waiting and more likely to receive brachytherapy or hormonal therapy. Relatively few patients treated with radical prostatectomy in the database are under graded or under staged before surgery, whereas the surgical margin rate is comparable to that in academic series. CaPSURE data confirm the usefulness of percent positive biopsies in risk assessment and they have further been used to validate multiple preoperative nomograms. CaPSURE results strongly affirm the necessity of patient reported quality of life assessment. Multiple studies have compared the quality of life impact of various treatment options, particularly in terms of urinary and sexual function, and bother.

CONCLUSIONS

The presentation and management of prostate cancer have changed substantially in the last decade. CaPSURE will continue to track these trends as well as oncological and quality of life outcomes, and will continue to be an invaluable resource for the study of prostate cancer at the national level.

Global registries for measuring pharmacoeconomic and quality-of-life outcomes: focus on design and data collection, analysis and interpretation

Disease registries have traditionally been vehicles for the collection of clinical data, in most instances following a large number of patients for a long time period in an observational manner, and enhancing our understanding of disease aetiology and epidemiology. However, over recent decades, the potential for additional data collection and analyses to be conducted within the framework of a registry has been recognised and utilised. This is evident by the sheer number of registries that are now referenced in the medical literature, covering a vast array of therapeutic areas and topics much more varied than incidence, prevalence and survival. The opportunity to collect QOL and pharmacoeconomic data has been utilised within the registry framework as more and more countries have increased their demands for such information for regulatory procedures, including pricing and reimbursement decisions. This increased need for information has led to a marked increase in the number of registries undertaken that are primarily sponsored by the pharmaceutical industry. Disease registries offer tremendous opportunities to realise improvements in care. The length of data collection and the large number of patients involved offer some unusual advantages for QOL and health economic analyses; however, these advantages are not yet fully exploited.

[Prostate cancer in the Community of Madrid in the year 2000. III. Study of tumor extent]

OBJECTIVE

To identify a potential relationship between two variables, risk of metastasis and use of imaging techniques, in an extension study in prostate cancer patients diagnosed in the Autonomous Community of Madrid in 2000.

MATERIAL AND METHODS

1,127 patients with available data on the tumour extension study were analysed. Performance and non performance of bone scans and CTs were correlated to risk variables for developing metastasis as described in the literature (PSA, Gleason and stage) and to therapy administered.

RESULTS

The proportion of patients with risk variables for metastasis when bone scans were performed was between 7% to 14% greater than in patients with no variables. No differences were seen for CTs based on risk variables. With matching risk variables, more imaging techniques were used in patients receiving radiotherapy that in those managed with prostatectomy.

CONCLUSION

Based on current recommendations imaging techniques were used in excess in the extension study in patients with no risk variables for metastasis. Conduct of a further study in the Autonomous Community seems advisable to confirm the likelihood of implementing such recommendations considering our prevalence of metastatic disease.

Investigation of the safety and accuracy of intraoperative gamma probe directed biopsy of bone scan detected rib abnormalities in prostatic adenocarcinoma

PURPOSE

We evaluated the technique of intraoperative gamma probe directed rib biopsy in patients with suspected metastatic prostate adenocarcinoma. This technique can be used to identify accurately the rib in question, reliably obtain sufficient tissue for diagnosis, be performed with minimal patient morbidity and potentially alter the course of therapy.

MATERIALS AND METHODS

From 1996 to 2001, 8 patients with biopsy proved adenocarcinoma of the prostate and suspicious rib lesions on radionuclide bone scanning underwent open rib biopsy as part of the evaluation for metastatic disease. Mean prostate specific antigen in the patient population was 17.1 ng/ml (range 6.1 to 36.5) and clinical stage was T1c to T3c. A new technique of intraoperative gamma probe directed biopsy was used to localize and resect the rib in question. At 6 to 12 hours before the operation each patient received an intravenous injection of 28 mCi. (99m)technetium-oxidronate. The hand held, pencil sized gamma probe in a sterile sleeve was used to localize the area of greatest activity in the target bone and 3 cm. of bone were resected.

RESULTS

Of the 8 patients who underwent the procedure 2 had metastatic prostate cancer on final rib pathological findings. Four of the remaining 5 patients had benign rib lesions (an old rib fracture) and 1 had metastatic lung cancer. The hot spot on bone scan was localized with 100% accuracy using our technique and a pathological diagnosis was made in all cases. Mean operative time was 61 minutes and estimated blood loss was less than 20 ml. in all cases. Seven of the 8 patients were discharged home the same day, while 1 required overnight hospitalization. There was 1 intraoperative complication of inadvertent entry into the pleural cavity, resulting in a small pneumothorax, which was treated with small chest catheter drainage and observation.

CONCLUSIONS

Intraoperative gamma probe directed rib biopsy of suspected metastatic lesions in patients with prostate cancer can be safely and accurately performed with minimal patient morbidity. The information obtained using this technique can be used to tailor treatment decisions for this subset of patients with prostate cancer.

Quality of life and economic considerations in the management of prostate cancer

The purpose of this article was to provide an overview of the morbidity and mortality of prostate cancer, QOL issues and the economic impact of the disease. We searched Medline (from 1990 onwards) for all studies dealing with prostate cancer epidemiology, treatment, screening and staging, and critically reviewed the most relevant articles, focusing on pharmacoeconomic issues. Prostate cancer is the most common cancer in men. In the US, new estimated cases of prostate cancer represented 14.8% of all new cancer cases for 2000, with estimated deaths from prostate cancer comprising 5.8% of all deaths from cancer. Current options for prostate cancer management include radical prostatectomy, cryosurgery, radiotherapy, hormone therapy and watchful waiting. Many of the long-term effects of treatment, such as urinary incontinence, impotence and radiation-induced proctitis, have a large impact on patients' quality of life and, in some patients, may offset the clinical benefits. Regulatory bodies and managed care organisations are assigning increasing importance to the evaluation of QOL benefits as an independent clinical endpoint and a measure of patient satisfaction. Several screening programmes for early detection of prostate cancer, mostly based on prostate-specific antigen (PSA) measurement or digital rectal examination, have been proposed, but their routine implementation in all asymptomatic elderly men has been questioned. There is still no definite proof that patient outcomes are improved by extensive PSA screening. Furthermore, the total cost of a screening programme is difficult to define since it extends well beyond the initial test. Several instruments are used for QOL assessment in prostate cancer, some of which have been specifically developed for, or adapted to, patients with this disease, such as the Functional Assessment Cancer Therapy (FACT) tool, Prostate Cancer Treatment Outcome Questionnaire (PCTO-Q) and Prostate Cancer Specific Quality of Life Instrument (PROSQOLI). More than 50% of treatment costs for prostate cancer are accrued during the patient's last year of life, and total initial care costs decrease with increasing age. In the US, initial average inpatient costs were estimated at $US 2253, in 1995, for men aged > or =80 years, compared with $US 4540 for men aged 35-64 years. In recent years, treatments based on combined modalities (i.e. radiotherapy/prostatectomy plus hormonal therapies) have emerged. Although cost-effectiveness analyses of various treatment options have been attempted, the strength of their conclusions appears to be limited by the lack of homogeneous literature data on the effects of such interventions on survival and morbidity.

Variations in use of imaging in a national sample of men with early-stage prostate cancer

OBJECTIVES

To measure the national practice variations in imaging studies performed for men newly diagnosed with clinically localized prostate cancer.

METHODS

We created an analytic file from 1991 to 1996 Medicare claims data using files for a random sample of 5% of all Medicare beneficiaries. Among men with newly diagnosed clinically localized prostate cancer, we identified those undergoing staging bone scans, staging computed tomography (CT), or staging magnetic resonance imaging (MRI) at the time of diagnosis. We conducted univariate and multivariate analyses adjusting for Charlson index score, age group, race, geographic region, and year of diagnosis.

RESULTS

In all geographic regions, men receiving radiation therapy (RT) were more likely than those receiving radical prostatectomy (RP) to undergo CT. In the South, RT patients were significantly more likely than RP patients to undergo MRI and bone scans. In the West, RT patients were significantly more likely than RP patients to have bone scans. In multivariate analyses that controlled for all significant univariate findings, treatment with RT significantly predicted for the use of bone scans (odds ratio 1.24, 95% confidence interval 1.17 to 1.31), CT scans (odds ratio 3.26, 95% confidence interval 3.18 to 3.34), and MRI scans (odds ratio 1.47, 95% confidence interval 1.23 to 1.72). Regional differences in the use of imaging technologies for staging persisted in the multivariate analysis.

CONCLUSIONS

Patients undergoing RT for clinically localized prostate cancer undergo more bone, CT, and MRI scans than do patients undergoing RP, regardless of comorbidity, age, or race. In addition, a significant geographic variation was found in the use of these diagnostic tests. These variations suggest that evidence-based staging guidelines have not been met with broad physician acceptance.

The role of imaging studies and molecular markers for selecting candidates for radical prostatectomy

For the typical patient who has newly diagnosed prostate cancer, clinically organ-confined disease of moderate grade, and a PSA less than 10 ng/mL, the current role of imaging studies and molecular biomarkers is limited. Bone scans are not necessary for newly diagnosed men with a PSA less than 10 ng/mL in the absence of bone pain. Similarly, abdominal and pelvic CT scanning rarely provides any useful diagnostic or staging information when the PSA is less the 20 ng/mL and is indicated rarely. Endorectal coil MR imaging adds staging information for patients with a PSA between 10 and 20 ng/mL, a Gleason score of 7 or less, and 50% or more positive biopsies on a sextant sampling. Indium 111 capromab pendetide scanning (ProstaScint) is FDA-approved to evaluate newly diagnosed patients at high risk for metastases. These patients have a Gleason score of 7 or greater and a PSA greater than 20 ng/mL, a Gleason score of 8 to 10 regardless of the PSA value, or clinical stage T3 disease and a Gleason score of 6 or greater. RT-PCR testing of blood or bone marrow for prostate-specific or prostate cancer-specific gene expression, or "molecular staging," is a promising technique whose current use is still investigational. Much useful information may be gained by careful study of prostate needle biopsy material. Aside from current Gleason grading and the number or percentage of cores involved with cancer, no molecular biomarker is approved for clinical use. p27, p53, bcl-2, Ki-67 (MIB-1), and the assessment of neovascularity hold promise, but prospective multicenter studies are needed. In the long-term, multiple gene expression profiling of biopsy material using gene chips may revolutionize the care of patients with prostate cancer and those who elect radical prostatectomy.