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

Barriers and enablers of active surveillance for prostate cancer: a qualitive study of clinicians

OBJECTIVES

To identify and explore barriers to, and enablers of, active surveillance (AS) in men with low-risk prostate cancer (LRPCa), as perceived by PCa clinicians.

PATIENTS AND METHODS

Urologists and radiation oncologists in Australia and New Zealand were purposively sampled for a cross-section on gender and practice setting (metropolitan/regional; public/private). Using a grounded theory approach, semi-structed interviews were conducted with participants. Interviews were coded independently by two researchers using open, axial, and selective coding. A constant comparative approach was used to analyse data as it was collected. Thematic saturation was reached after 18 interviews, and a detailed model of barriers to, and enablers of, AS for LRPCa, as perceived by clinicians was developed.

RESULTS

A model explaining what affects clinician decision making regarding AS in LRPCa emerged. It was underpinned by three broad themes: (i) clinician perception of patients' barriers and enablers; (ii) clinician perception of their own barriers and enablers; and (iii) engagement with healthcare team and resource availability.

CONCLUSIONS

Clinicians unanimously agree that AS is an evidence-based approach for managing LRPCa. Despite this many men do not undergo AS for LRPCa, which is due to the interplay of patient and clinician factors, and their interaction with the wider healthcare system. This study identifies strategies to mitigate barriers and enhance enablers, which could increase access to AS by patients with LRPCa.

Descriptive analysis of prostate cancer pathology data from diagnosis and surgery in men from the 45 and Up Study

Information available from the New South Wales Cancer Registry (NSWCR) about the aggressiveness of prostate cancer is limited to the summary stage variable 'degree of spread', which contains a high proportion of cases defined as 'unknown'. In this study we demonstrate the feasibility of obtaining and analysing prostate cancer pathology data from stored pathology records. Pathology data were extracted from stored pathology records of incident prostate cancer cases in men participating in the 45 and Up Study, a large Australian prospective cohort study, who were diagnosed between January 2006 and December 2013. Baseline questionnaires from the 45 and Up Study were linked to the NSWCR. Demographic and pathology items were tabulated and associations described. We evaluated the completeness of pathological characteristics by degree of spread of cancer at diagnosis. Among the 123,921 men enrolled in the 45 and Up Study, 5,091 had incident prostate cancer and 5,085 were linked to a pathology record. The most complete variables included grade group of diagnostic (85.8%) and surgical (99.8%) specimens, margin status (98.1%), extraprostatic extension (95.1%) and seminal vesicle invasion (96.8%). Most diagnostic specimens were grade group 1 (26.6%) or 2 (23.5%). Of the 5,085 cases, 30.8% were classified by the NSWCR with unknown degree of spread; a pathology record could be extracted for 99.4% of these. The unknown degree of spread cases had similar levels of completeness and distribution of diagnostic and surgical pathology features to those with a localised degree of spread. This study demonstrated the feasibility of obtaining and analysing data derived from pathology reports from centralised state-based cancer registry notifications. Supplementing degree of spread information with pathology data from diagnosis and surgery will improve both the quality of research and policy aimed at improving the lives of men with prostate cancer.

Quality of Care for Prostate Cancer in Kashmir, India: A Real-World Study

Purpose Despite the importance of quality care for patients with prostate cancer, significant gaps exist in healthcare delivery, including diagnosis and treatment. Our objective was to assess the quality of care (QoC) using retrospective data from prostate care patients in our center. Methods We performed a retrospective study of prostate cancer patients registered at a dedicated cancer care center in the Kashmir region from 2012 to 2020. A set of 15 quality indicators representing crucial facets of diagnosis, pathology, and treatment was identified from a comprehensive list developed and validated by other researchers. Results The final analysis of all indicators was conducted on 46 patients with a median age of 70 years (52-92 years). In the majority of patients, the diagnosis (89.1%) was made through a prostatic biopsy, while only five patients were diagnosed solely based on the prostate-specific antigen. Transrectal ultrasound (TRUS) or transurethral resection (TURP)-guided biopsy was documented in 84.8% of patients, with Gleason grading documented in 87.5% of patients. However, the number of positive cores was mentioned for only 25.7% of patients. Radical prostatectomy was the primary treatment for most patients with localized prostate cancer (58.3%). The majority of patients with metastatic prostate cancer were treated with orchidectomy (55%), owing to easy access and the lower cost of surgical castration. Conclusion The study demonstrated a lack of compliance with many QoC indicators at the diagnostic and therapeutic levels. However, large-scale, population-based studies are needed to establish the compliance of prostate cancer QoC in Kashmir. The quality indicator assessment can guide the necessary actions required to improve QoC for prostate cancer patients.

Radical prostatectomy trends between 2010 and 2020 in Ehime, Japan, identified using data from the Medical Investigation Cancer Network (MICAN) study

OBJECTIVES

The use of radical prostatectomy is increasing with the rising incidence of prostate cancer. We assessed the surgical trends related to radical prostatectomy using data from a multi-center, retrospective cohort study, the MICAN (Medical Investigation Cancer Network) study, which was conducted in all the urology-related medical facilities in Ehime Prefecture, Japan.

METHODS

We compared data from the MICAN study with prostate biopsy registry data collected in Ehime between 2010 and 2020 and recorded the surgical trends.

RESULTS

There was a significant increase in the mean age of patients with positive biopsies, and the positivity rate increased from 46.3% in 2010 to 60.5% in 2020, while the number of biopsies obtained decreased. The number of radical prostatectomies performed increased over the years, with robot-assisted radical prostatectomy becoming the predominant procedure. In 2020, robot-assisted radical prostatectomies accounted for 96.0% of the surgeries performed. The age at surgery also gradually increased. Of the registered patients aged ≤75 years, 40.5% underwent surgery in 2010, compared with 83.1% in 2020. The prevalence of surgery also increased from 4.6% to 29.8% in patients aged >75 years. There was a gradual increase in the proportion of high-risk cases, from 29.3% to 44.0%, but a decrease in that of low-risk cases, from 23.8% in 2010 to 11.4% in 2020.

CONCLUSIONS

We have shown that the number of radical prostatectomies performed in Ehime is increasing in patients aged both ≤75 and >75 years. The proportion of low-risk cases has decreased, while that of high-risk cases has increased.

Why do men with prostate cancer discontinue active surveillance for definitive treatment? A mixed methods investigation

Objectives

To explore the personal and/or medical reasons patients on active surveillance (AS) have, or consider having, further definitive treatment for their prostate cancer. Research suggests up to 50% of patients on AS will discontinue within 5 years, though reasons for discontinuation from the patient's perspective is under‐explored.

Methods

Prostate cancer patients who were or had been on AS for at least 6 months were recruited. A questionnaire assessed reasons for receiving/considering definitive treatment and the extent to which reasons were personal or medical. Clinical information was extracted from a state‐level population registry. A subset of participants were interviewed to further explore questionnaire responses.

Results

One‐hundred and‐three individuals completed the survey; 33 were also interviewed. Fifty‐four survey participants (52%) had discontinued AS for definitive treatment. Common reasons for discontinuation were evidence of disease progression, doctor recommendation, desire to act, and fear of progression. Many participants who considered or had treatment reported weighing medical and personal factors equally in their decision. Interview participants described strongly considering any amount of disease progression and personal factors such as fear of progression, family concerns, and adverse vicarious experiences when deciding whether to pursue treatment.

Conclusion

Both medical and personal factors are considered when deciding whether to discontinue AS. Identifying predictors of discontinuation is essential for informing supportive care services to improve AS management.

Urban-rural prostate cancer disparities in a regional state of Australia

Men living in regional and remote areas experience disparities in prostate cancer (PrCa) diagnosis, clinical characteristics and treatment modalities. We sought to determine whether such disparities exist in PrCa patients from Tasmania; a regional state of Australia with the second-highest rate of diagnosis and where over a third of residents live in outer regional and remote areas. Our study included clinicopathological data from 1526 patients enrolled in the Prostate Cancer Outcomes Registry-Tasmania. Regression analyses were undertaken to determine whether demographic, clinical and treatment variables differed between inner regional and outer regional/remote patients. Men from outer regional/remote areas were significantly more likely to reside in lower socio-economic areas, be diagnosed at a later age and with more clinically aggressive features. However, in contrast to previous studies, there were no overall differences in diagnostic or treatment method, although men from outer regional/remote areas took longer to commence active treatment and travelled further to do so. This study is the first to investigate PrCa disparities in a wholly regional Australian state and highlights the need to develop systematic interventions at the patient and healthcare level to improve outcomes in outer regional and remote populations in Australia and across the globe.

Health Economic Evidence for Liquid- and Tissue-based Molecular Tests that Inform Decisions on Prostate Biopsies and Treatment of Localised Prostate Cancer: A Systematic Review

Context

Several liquid- and tissue-based biomarker tests (LTBTs) are available to inform the need for prostate biopsies and treatment of localised prostate cancer (PCa) through risk stratification, but translation into routine practice requires evidence of their clinical utility and economic impact.

Objective

To review and summarise the health economic evidence on the ability of LTBTs to inform decisions on prostate biopsies and treatment of localised PCa through risk stratification.

Evidence acquisition

A systematic search was performed in the EMBASE, MEDLINE, Health Technology Assessment, and National Health Service Health Economic Evaluation databases. Eligible publications were those presenting health economic evaluations of an LTBT to select individuals for biopsy or risk-stratify PCa patients for treatment. Data on the study objectives, context, methodology, clinical utility, and outcomes were extracted and summarised.

Evidence synthesis

Of the 22 studies included, 14 were focused on test-informed biopsies and eight on treatment selection. Most studies performed cost-effectiveness analyses (n = 7), followed by costing (n = 4) or budget impact analyses (n = 3). Most (18 of 22) studies concluded that biomarker tests could decrease health care costs or would be cost-effective. However, downstream consequences and long-term outcomes were typically not included in studies that evaluated LTBT to inform biopsies. Long-term effectiveness was modelled by linking evidence from different sources instead of using data from prospective studies.

Conclusions

Although studies concluded that LTBTs would probably be cost-saving or -effective, the strength of this evidence is disputable because of concerns around the validity and transparency of the assumptions made. This warrants prospective interventional trials to inform health economic analyses to ensure collection of direct evidence of clinical outcomes based on LTBT use.

Patient summary

We reviewed studies that evaluated whether blood, urine, and tissue tests can reduce the health and economic burden of prostate cancer. Results indicate that these tests could be cost-effective, but clinical studies of long-term outcomes are needed to confirm the findings.

Patterns of care for men with prostate cancer: the 45 and Up Study

OBJECTIVES

To describe patterns of care in New South Wales for men with prostate cancer, and to ascertain factors associated with receiving different types of treatment.

DESIGN

Individual patient data record linkage study.

SETTING, PARTICIPANTS

4003 New South Wales men aged 45 years or more enrolled in the population-based 45 and Up Study in whom prostate cancer was first diagnosed during 2006-2013.

MAIN OUTCOME MEASURES

Prostate cancer treatment type received; factors statistically associated with treatment received; proportions of patients who consulted radiation oncologists prior to treatment.

RESULTS

In total, 1619 of 4003 patients underwent radical prostatectomy (40%), 893 external beam radiotherapy (EBRT) (22%), 183 brachytherapy (5%), 87 chemotherapy (2%), 373 androgen deprivation therapy alone (9%), and 848 no active treatment (21%). 205 of 1628 patients who had radical prostatectomies (13%) had radiation oncology consultations prior to surgery. Radical prostatectomy was more likely for patients aged 45-59 years, with regional stage disease, living 100 km or more from the nearest radiotherapy centre, having partners, or having private health insurance, while lower physical functioning, obesity, and living in areas of greater socio-economic disadvantage reduced the likelihood. EBRT was more likely for patients aged 70-79 years, with non-localised or unknown stage disease, living less than 100 km from the nearest radiotherapy centre, or not having private health insurance, while the likelihood was lower for patients aged 45-59 years or more than 80 years and for those who had several comorbid conditions.

CONCLUSIONS

Men with prostate cancer were twice as likely to have radical prostatectomy as to receive EBRT, and fewer than one in seven had consulted radiation oncologists prior to prostatectomy. The treatment received was influenced by several socio-demographic factors. Given the treatment-specific side effects and costs, policies that affect access to different treatments for prostate cancer should be reviewed.

Survival outcomes in men with a positive family history of prostate cancer: a registry based study

Background

To investigate the correlation between family history of prostate cancer (PCa) and survival (overall and cancer specific) in patients undergoing treatment for PCa.

Methods

ine thousand four hundred fifty-nine patients with PCa were extracted from the South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC) database. Diagnosis occurred after 1998 and treatment before 2014. Cox proportional-hazards modeling was used to assess the effect of family history on overall survival after adjustment for confounders (age at diagnosis, NCCN risk category and year of treatment), and with stratification by primary treatment group. Competing risks regression modelling was used to assess PCa specific mortality.

Results

Men with a positive family history of PCa appear to have a lower Gleason score at the time of diagnosis (50% with Gleason < 7, compared to 39% in those without family history) and be diagnosed at a lower age (64 vs 69). Men with a positive family history of PCa appear to have better overall survival outcomes (p < 0.001, log rank test). In analysis adjusting for age at diagnosis, NCCN risk category and year of treatment, family history remained a significant factor when modelling overall survival (HR 0.72 95% CI 0.55–0.95, p = 0.021).

There were no significant differences in treatment subgroups of radical prostatectomy (p = 0.7) and radiotherapy (0.054).

Conclusion

Men with a positive family history of PCa appear to have better overall survival outcomes. This better survival may represent lead time bias and early initiation of PSA screening. Family history of PCa was not associated with different survival outcomes in men who were treated with either radical prostatectomy or radiotherapy.

A systematic review of the unmet supportive care needs of men on active surveillance for prostate cancer

OBJECTIVE

Understanding the unmet supportive care needs of men on active surveillance for prostate cancer may enable researchers and health professionals to better support men and prevent discontinuation when there is no evidence of disease progression. This review aimed to identify the specific unmet supportive care needs of men on active surveillance.

METHODS

A systematic review following PRISMA guidelines was conducted. Databases (Pubmed, Embase, PsycINFO, and CINAHL) were searched to identify qualitative and/or quantitative studies that reported unmet needs specific to men on active surveillance. Quality appraisals were conducted before results were narratively synthesised.

RESULTS

Of the 3613 unique records identified, only eight articles were eligible (five qualitative and three cross-sectional studies). Unmet Informational, Emotional/Psychological, Social, and "Other" needs were identified. Only three studies had a primary aim of investigating unmet supportive care needs. Small active surveillance samples, use of nonvalidated measures, and minimal reporting of author reflexivity in qualitative studies were the main quality issues identified.

CONCLUSIONS

The unmet needs of men on active surveillance is an underresearched area. Preliminary evidence suggests the information available and provided to men during active surveillance is perceived as inadequate and inconsistent. Men may also be experiencing unmet psychological/emotional, social, and other needs; however, further representative, high-quality research is required to understand the magnitude of this issue. Reporting results specific to treatment type and utilising relevant theories/models (such as the social ecological model [SEM]) is recommended to ensure factors that may facilitate unmet needs are appropriately considered and reported.

Identifying the exercise-based support needs and exercise programme preferences among men with prostate cancer during active surveillance: A qualitative study

PURPOSE

This study aims to investigate the attitudes and preferences men on active surveillance for prostate cancer have regarding exercise and exercise-based support. Exercise outcomes align with traditionally masculine values, can improve mental and physical health, and may even slow early stage prostate cancer progression. However, attitudes and preferences towards exercise and exercise support are unexplored in men on active surveillance.

METHODS

Semi-structured qualitative interviews were conducted with participants (13 males with a history of active surveillance for prostate cancer; 5 female partners). Interviews were conducted either by telephone or in person and audiotaped, transcribed verbatim, and thematically analysed.

RESULTS

Several key themes were identified relating to the two research aims: 'Attitudes and Preferences towards Exercise, and 'Attitudes and Preferences towards Exercise Support'. Despite all men engaging in exercise, the majority did not meet the recommended guidelines for cancer survivors. The majority of men either were interested in receiving exercise support or had previously received it, often recommending this for all men on active surveillance. There were varied preferences regarding delivery modality (i.e., online or face to face), the inclusion of partners, and group versus individual formats.

CONCLUSIONS

This study provides a novel insight into the attitudes and preferences of men on active surveillance regarding exercise and support. This research will help the development of acceptable and accessible person-centred support for men on active surveillance. However, further research is needed to evaluate the efficacy of different delivery modalities in this population.

Long-term outcomes in 1121 Australian prostate cancer patients treated with definitive radiotherapy

INTRODUCTION

Optimal definitive treatment of prostate cancer is controversial, especially in high-risk patients. We report the largest prospective cohort of Australian patients treated with radiotherapy for localised prostate cancer.

METHODS

One thousand, one hundred and twenty-one patients with prostate cancer were prospectively registered and treated to a dose of 70-74 Gy. Patients were classified as low, intermediate or high risk based on PSA, clinical staging and Gleason score. Intermediate-risk patients were treated with 0-6 months of hormonal therapy (ADT) and high-risk patients were offered neoadjuvant and adjuvant ADT. Overall survival (OS) and biochemical relapse-free survival (bNED) were calculated using the Kaplan-Meier method.

RESULTS

Median follow-up was 92 months. Eight-year OS and bNED were 78.4% and 68.1% respectively in the entire cohort. OS for the low, intermediate and high-risk groups was 84.5%, 78.4% and 68% respectively. For these risk groups, bNED was 80.3%, 65.7% and 53.7% respectively. In the intermediate and high-risk group, OS and bNED decreased with increasing number of risk factors.

CONCLUSION

Definitive radiotherapy is an effective treatment for prostate cancer, including in high-risk cases.

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.

Observation versus treatment among men with favorable risk prostate cancer in a community-based integrated health care system: a retrospective cohort study

Background

The objective of this study was to describe overall survival and the management of men with favorable risk prostate cancer (PCa) within a large community-based health care system in the United States.

Methods

A retrospective cohort study was conducted using linked electronic health records from men aged ≥40 years with favorable risk PCa (T1 or 2, PSA ≤15, Gleason ≤7 [3 + 4]) diagnosed between January 2005 and October 2013. Cohorts were defined as receiving any treatment (IMT) or no treatment (OBS) within 6 months after index PCa diagnosis. Cohorts’ characteristics were compared between OBS and IMT; monitoring patterns were reported for OBS within the first 18 and 24 months. Cox Proportional Hazards models were used for multivariate analysis of overall survival.

Results

A total of 1425 men met the inclusion criteria (OBS 362; IMT 1063). The proportion of men managed with OBS increased from 20% (2005) to 35% (2013). The OBS group was older (65.6 vs 62.8 years, p < 0.01), had higher Charlson comorbidity index scores (CCI ≥2, 21.5% vs 12.2%, p < 0.01), and had a higher proportion of low-risk PCa (65.2% vs 55.0%, p < 0.01). For the OBS cohort, 181 of the men (50%) eventually received treatment. Among those remaining on OBS for ≥24 months (N = 166), 88.6% had ≥1 follow-up PSA test and 26.5% received ≥1 follow-up biopsy within the 24 months. The unadjusted mortality rate was higher for OBS compared with IMT (2.7 vs 1.3/100 person-years [py]; p < 0.001). After multivariate adjustment, there was no significant difference in all-cause mortality between OBS and IMT groups (HR 0.73, p = 0.138).

Conclusions

Use of OBS management increased over the 10-year study period. Men in the OBS cohort had a higher proportion of low-risk PCa. No differences were observed in overall survival between the two groups after adjustment of covariates. These data provide insights into how favorable risk PCa was managed in a community setting.

Metastatic prostate cancer incidence in Australia after amendment to prostate-specific antigen screening guidelines

BACKGROUND

To compare the incidence of newly diagnosed metastatic prostate cancer at an Australian facility pre- and post-publication of the United States Preventive Services Task Force (USPSTF) guidelines and subsequent amendment of the Royal Australian College of General Practitioners Preventive Activities in General Practice guidelines.

METHODS

A retrospective analysis was undertaken by patients with newly diagnosed prostate cancer following transrectal ultrasound-guided biopsy between 2009 and 2014. Patients were divided into two even groups based on whether they had undergone their transrectal ultrasound biopsy pre- (2009-2011) or post- (2013-2014) publication of USPSTF guidelines. Metastatic disease was determined by computed tomography chest, abdomen, pelvis as well as nuclear medicine bone scan. A comparison in the incidence of newly diagnosed metastatic prostate cancer was made.

RESULTS

A total of 130 patients were allocated into each group. In the pre-USPSTF group, 23 out of 130 patients had newly diagnosed metastatic prostatic cancer (17.7%). In the post-USPSTF group, 41 out of 130 (31.5%) had newly diagnosed metastatic prostate cancer (P < 0.05). The mean and median prostate-specific antigen was 15.9 and 9.4 (pre-guideline group) and 33.0 and 9.8 (post-guideline group), respectively (P = 0.02). The post-guidelines group had a higher incidence of low-grade disease (Gleason <7), a decreased incidence of intermediate grade disease (Gleason 7) and a relatively unchanged incidence in high-risk disease (Gleason >7).

CONCLUSION

The incidence of newly diagnosed metastatic prostate cancer nearly doubled in patients referred to our Urology Department post-release of the USPSTF guidelines.

Phase of care prevalence for prostate cancer in New South Wales, Australia: A population-based modelling study

Objective

To develop a method for estimating the future numbers of prostate cancer survivors requiring different levels of care.

Design, setting and participants

Analysis of population-based cancer registry data for prostate cancer cases (aged 18–84 years) diagnosed in 1996–2007, and a linked dataset with hospital admission data for men with prostate cancer diagnosed during 2005–2007 in New South Wales (NSW), Australia.

Methods

Cancer registry data (1996–2007) were used to project complete prostate cancer prevalence in NSW, Australia for 2008–2017, and treatment information from hospital records (2005–2007) was used to estimate the inpatient care needs during the first year after diagnosis. The projected complete prevalence was divided into care needs-based groups. We first divided the cohort into two groups based on patient’s age (<75 and 75–84 years). The younger cohort was further divided into initial care and monitoring phases. Cause of death data were used as a proxy for patients requiring last year of life prostate cancer care. Finally, episode data were used to estimate the future number of cases with metastatic progression.

Results

Of the estimated total of 60,910 men with a previous diagnosis of prostate cancer in 2017, the largest groups will be older patients (52.0%) and younger men who require monitoring (42.5%). If current treatment patterns continue, in the first year post-diagnosis 41% (1380) of patients (<75 years) will have a radical prostatectomy, and 52.6% (1752) will be likely to have either active surveillance, external beam radiotherapy or androgen deprivation therapy. About 3% will require care for subsequent metastases, and 1288 men with prostate cancer are likely to die from the disease in 2017.

Conclusions

This method extends the application of routinely collected population-based data, and can contribute much to the knowledge of the number of men with prostate cancer and their health care requirements. This could be of significant use in planning future cancer care services and facilities in Australia.