PCa Care Mostly Follows Guidelines

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SAN DIEGO—Most prostate cancer (PCa) patients receive care according to National Comprehensive Cancer Network (NCCN) guidelines, but guideline compliance varies significantly by risk group, age, and geographic location, study findings show.

Presented at the 52nd annual meeting of the American Society of Radiology Oncology, the study, by researchers at Tufts University and Tufts Medical Center in Boston, examined data from the SEER (Surveillance, Epidemiology and End Results) database to evaluate compliance with NCCN guidelines for the initial therapy of patients with non-metastatic PCa.

Noting that compliance with treatment guidelines has been shown to improve outcomes, decrease morbidity, and lower care costs, the researchers analyzed information on 37,646 men diagnosed with metastatic prostate cancer in 2006 and who had sufficient information on their T-stage, PSA, and Gleason score.

After stratifying each case into a low-risk, intermediate-risk, high-risk, or locally advanced group, the researchers compared the treatment given with the care outlined in the 2005 NCCN guidelines, ultimately determining if the care was concordant, discordant, or unknown based on the guidelines. The investigators considered care to be unknown when different treatment alternatives were available based on the patient's expected survival, which was not readily available via SEER data. The team also conducted a subset analysis based on risk group, age, race, and geography.

Overall, therapy was concordant with NCCN guidelines in 65% of patients, discordant in 17%, and unknown in 18%, numbers the researchers considered to show a “reasonably high level of compliance.” However, subset analysis revealed that treatment compliance varied widely by risk category, patient age, and geography.

For example, while only 8% of low-risk patients and 12% of intermediate-risk patients received discordant therapy, the numbers rose considerably for high-risk patients and patients with locally advanced disease, at 43% and 39%, respectively.

In addition, 6% of men in their 40s received discordant therapy, compared with 40% of men in their 80s (men in their 50s, 60s, and 70s received discordant care in 10%, 14%, and 21% of cases, respectively). The proportion of discordant cases ranged from a low of 8% in Alaska to a high of 30% in Georgia. The researchers found no significant variation based on race, however: 17% of white patients and 19% of black patients received discordant therapy.

According to the researchers, the reasons for discordant care included the use of cryotherapy, combining brachytherapy and external beam radiation therapy for low-risk patients, providing brachytherapy alone for patients at intermediate risk, using watchful waiting/active surveillance for high-risk patients, and performing radical prostatectomy for locally advanced patients.

According to senior study author Tomas Dvorak, MD, of the Department of Radiation Oncology at Tufts, the issue is more complicated than merely determining a benchmark percentage for concordance. “It's not clear what the ultimate target compliance number should be, since some patients may be receiving appropriate care without  following guidelines,” Dr. Dvorak said.

“For example, patients who are enrolled on clinical trials should be exempt from following guidelines, and, for some patients who have severe comorbidities with short life expectancy, it's reasonable not to offer curative care. What I suspect will happen is that payers will mandate that a specific proportion of patients must be treated according to guidelines, and justifications will have to be made for deviating from them.”

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