Treatment patterns for older veterans with localized prostate cancer

Abstract

Objective: Concerns about over-treatment have led to practice guidelines discouraging active treatment of prostate cancer (PCa) in men with limited life expectancies and/or low-risk tumors. We evaluated treatment patterns for older veterans with localized PCa, particularly those with low-risk features. Methods: We used VA Cancer Registry data to identify men aged 65+ diagnosed with clinically localized PCa between January 1st, 2003 and December 31st, 2008. We obtained baseline data on demographics, tumor characteristics, comorbidities, and initial treatment within 6 months of diagnosis: radical prostatectomy, radiotherapy, primary androgen-deprivation therapy (PADT), or no active treatment. National VA surveys provided facility data, including academic affiliation, availability of oncologic specialists, and distance to radiotherapy facilities. Multinomial regression analyses determined associations between patient and facility characteristics and cancer treatment for men with localized (stage. < III) and low-risk PCa (stage. ≤ IIa, PSA. <10 ng/mL, Gleason ≤6). Results: 17,206 veterans had localized PCa, 32% age 75+, 12% had comorbidity scores ≥3, and 33% had low-risk tumors. Overall, 39% received radiotherapy, 6% surgery, 20% PADT, and 35% no active treatment. For those with low-risk cancers, older men (RR = 0.36, 95% CI 0.30-0.43) and sicker men (RR = 0.75, 95% CI 0.62-0.90) were less likely to receive surgery or radiotherapy versus no active treatment. Over time, more of these men received no active treatment (from 41% to 57%, P< 0.001) while fewer received PADT (from 11% to 4%, P< 0.001). Conclusion: VA treatment patterns followed evidence-based guidelines against treating older and sicker men with surgery or radiotherapy, for decreasing use of PADT, and for increasingly withholding active treatment, particularly for men with low-risk PCa.