Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011

The Victorian Cancer Registry estimates that the number of men diagnosed with cancer will increase by 75% in the next 10 years, largely due to prostate cancer — the most common cancer diagnosis in men.1 Algorithms have been developed to calculate risk of prostate cancer progression at time of diagnosis for men with localised disease, classifying men into four groups: very low, low, intermediate and high risk of recurrence (Appendix 1).2,3 The National Comprehensive Cancer Network (NCCN) guidelines suggest that many men with very low-risk clinically localised disease should be managed with active surveillance; men with low-risk and intermediate-risk disease should be managed with active surveillance or with external beam radiation therapy (EBRT), radical prostatectomy (RP), brachytherapy, or a combination of these treatments; and men with high-risk disease should be managed with EBRT and androgen deprivation therapy (ADT), or EBRT, high dose rate brachytherapy and ADT, or RP and pelvic node dissection.2

Few studies have compared the effectiveness of treatments for localised disease.4 The recently published Prostate Cancer Intervention Versus Observation Trial (PIVOT) — a randomised control trial comparing RP with watchful waiting in 731 US patients with localised prostate cancer disease — showed that RP was associated with reduced all-cause mortality for men with a prostate-specific antigen (PSA) level greater than 10 ng/mL but that it offered no survival benefit to men with a PSA level of 10 ng/mL or less.5 A systematic review comparing disease-free survival for low dose rate brachytherapy with other treatments for men with clinically localised prostate cancer found no significant difference when compared with RP.6

Little is known about current patterns of care for men diagnosed with prostate cancer in Australia and whether treatment correlates with clinical practice guidelines. A population-based patterns-of-care survey conducted in Victoria in 1993 showed that 11% of men diagnosed with prostate cancer had received the diagnosis following informal screening and 25% received definitive curative therapy.7 New South Wales data show that the annual number of PSA tests performed more than doubled, from 184 350 tests in 1996 to 433 187 in 2006.8 The impact that this has had on patterns of care is unknown.

Our aim was to use the Prostate Cancer Registry to assess patterns of care for men diagnosed with prostate cancer at contributing hospitals in Victoria.

The Prostate Cancer Registry was established as a rapid case-ascertainment registry in 2009 to monitor patterns and quality of care for Victorian men diagnosed with prostate cancer. Details of the registry, including methods for data collection, are described elsewhere.9 Initially, four hospitals (three metropolitan, one regional) contributed data, accounting for about 25% of all Victorian patients with newly diagnosed prostate cancer (calculated based on 2009 incident notification data supplied to the Victorian Cancer Registry). Addition of 13 hospitals in 2010 increased capture to about 75% of newly diagnosed patients in Victoria. With Human Research Ethics Committee approval from the hospitals that contributed data to the Prostate Cancer Registry, prostate cancer notifications that were submitted by these hospitals to the Victorian Cancer Registry are also forwarded to the Prostate Cancer Registry.

The recruitment of patients for the study is summarised in Box 1. A total of 3268 notifications were received before 1 February 2012 by the Prostate Cancer Registry for the period August 2008 to February 2011. In total, 492 men (15.1%) were ineligible. Of the 2776 who were eligible and for whom treatment data were sought, 52 (1.9%) did not provide consent for participation, leaving 2724 men (98.1%) for whom treatment data were collected and follow-up data were sought. As 697 men were lost to follow-up, confirmation of treatment and PSA levels were obtained for 2027 of the eligible men who provided consent for participation (74.4%).

Using Prostate Cancer Registry notifications, we documented patterns of care for Victorian men diagnosed with prostate cancer between August 2008 and February 2011 by collecting treatment data on 98.1% of those who were eligible to participate in the study and interviewing three-quarters of them at 12 months after diagnosis. Intermediate risk of disease progression was the most common NCCN risk category at diagnosis. Within 12 months of diagnosis, nearly half of men with localised disease had RP but more than one-tenth of those with high-risk localised disease had received no active treatment.

Men aged over 75 years were more than 10 times as likely not to receive active treatment compared with those younger than 55 years. Men for whom notifications of prostate cancer were made by private hospitals were significantly less likely to receive active treatment compared with those for whom notifications were made by public hospitals, and men with low-risk localised disease were significantly less likely to receive active treatment compared with men in all other risk categories. The likelihood of not receiving active treatment was inversely related to risk of disease progression.

From 1993 to 2008–2011, there were notable declines in the median PSA level at diagnosis and the percentage of men receiving no active treatment. However, this comparison is based on different methods of data collection — treatment for men in the 1993 study was determined by surveying the treating clinicians 3 years after diagnosis, whereas our 2008–2011 treatment data were collected 12 months after diagnosis. The proportion of men who had no active treatment in our study (22.7%) is similar to that in a US Medicare-linked study (about 23% for men diagnosed in 2007)10 and a South Australian study monitoring men treated in the public health system (about 20% of men diagnosed from 1998 to 2007).11 Men with low-risk disease in our study were four times more likely to receive no treatment compared with men with low-risk disease in 40 urology practices in the United States and recruited to the Cancer of the Prostate Strategic Urologic Research Endeavor (CAPSURE) registry (40.6% v 9%).12 This suggests that there is less overtreatment of patients with low-risk disease in Victoria compared with the US.

Our finding that almost half of men with clinically localised disease had RP is similar to the 50% rate of RP described for men recruited to the CAPSURE registry.12 In contrast, much lower rates have been reported elsewhere: 12%–16% in US Medicare-linked reviews (which captured only men older than 64 years and those with a disability or end-stage renal disease),10,13 11% in a population-based dataset from Northern England,14 23% in the study of men in South Australia who were treated in the public health system,11 and 13% in the previous study of men in Victoria.7

Our finding that 71.0% of men received surgery, radiotherapy and/or brachytherapy contrasts with results of the 1993 Victorian study, in which 25% of men received initial treatment with curative intent.7 Extrapolating this to statewide data using the Victorian Cancer Registry15 would equate to a sevenfold increase in the number of men having RP, from about 280 in 19937 to 2180 in 2010. Similarly, the proportion of men treated with EBRT and high dose rate brachytherapy has increased from 12.0% to 25.6%, or from about 230 men7 to 1370 men over the same period. In future, we expect that the proportion of men receiving robot-assisted laparoscopic RP (20.0% of those who had RP in our study) will increase, as the Prostate Cancer Registry did not receive notifications from facilities performing robot-assisted laparoscopic RP before December 2010.

We identified a sixfold decline in hormonal therapy as front-line treatment for prostate cancer compared with the 1993 Victorian study (38.8% to 6.0%).7 This downward trend was also reported in the South Australian study, although it was less pronounced (OR, 0.58 [95% CI, 0.40–0.82] for men diagnosed between 2004 and 2006 compared with those diagnosed between 1998 and 2000).11

The apparent change in patterns of prostate cancer management in Victoria is consistent with results of studies undertaken in Queensland16 and New South Wales.17 In contrast, the institutionally based South Australian registry shows a consistent proportion of men treated with RP (23% over the 1998–2007 study period), or possibly a slight decline.11

We found that the probability of receiving treatment declined as men aged and as the likelihood of disease progression increased, which is consistent with previous findings.7,12 Of particular interest was our finding that having a prostate cancer notification made by a private hospital was an independent factor for not receiving radical treatment, even after age and of risk of disease progression were taken into account. This contrasts the results of a US study, which showed that having private health insurance was associated with higher rates of treatment compared with not having private health insurance.18

A number of limitations affect the interpretation of our findings. While treatment data were collected for more than 98% of the eligible population, the sample was heavily biased towards men diagnosed and treated at metropolitan hospitals. In addition, hospitals were accrued progressively over the study period, which meant that treatment and outcomes from hospitals that contributed notifications from earlier in the study period were overrepresented. We were unable to interview a quarter of the men diagnosed with prostate cancer 12 months after diagnosis, including all those from non-English speaking backgrounds. This may have resulted in an underestimate of the number of men receiving active treatment and an overestimate of those on active surveillance or watchful waiting. We compared our findings with those from a 1993 patterns-of-care study that collected treatment data over a 3-year period. If our study was extended to include treatment data over a 3-year period, it is likely that an even higher percentage of men would have received active treatment, which would have made the difference between our study and the 1993 study even more pronounced. Another important limitation is that we did not seek to identify reasons why men received no treatment within 12 months of diagnosis. It may be that they were receiving active surveillance, had decided not to pursue active curative treatment, were awaiting therapy on the basis of their PSA level taken at 12 months, or were inadequately managed. Finally, the Prostate Cancer Registry did not collect cause of death, so some deaths may have been unrelated to prostate cancer disease.

The proportion of men receiving treatment with curative intent has increased substantially since 1993. There has also been a dramatic “stage migration” towards earlier diagnosis of prostate cancer — the vast majority of men in our study were diagnosed with localised disease and only 3.3% were diagnosed with metastatic disease. The Prostate Cancer Registry enables rapid and reliable ascertainment of such data on patterns and quality of care for men diagnosed with prostate cancer and reports patterns-of-care and quality indicator data back to clinicians who have contributed more than 20 cases to the registry via quarterly reports.

1 Recruitment of patients for the study

* Patients were interviewed to administer quality-of-life tools (no results of this are included in this article) and to confirm the treatment details that had been collected by data collectors. † Notification of cancer by the hospital was made more than 12 months after diagnosis.