Prostate Cancer Treatment Declines Sharply in General Population, But Not Among Diagnosed Men Interview with:
Tudor Borza, MD, MS
Urologic Oncology and Health Service Research Fellow
Department of Urology, University of Michigan What is the background for this study?

Response: Starting in the late 2000’s studies began to identify overdiagnosis and overtreatment in men with prostate cancer. Because of the indolent nature of some prostate cancers many men who ended up diagnosed and treated would have never had any consequences from their prostate cancer. This led national organizations (like the American Urological Association and the National Comprehensive Cancer Network) to call for decreased prostate cancer screening (using the serum PSA test) and eventually led to the US Preventive Services Task Force to recommend against routine PSA screening, citing that the harms from diagnosis and treatment outweighed the harms from the disease. Over the same specialists treating the disease began to report on the safety of surveillance strategies in select men with prostate cancer.

Watchful waiting (delaying any treatment until men become symptomatic from their cancer and then offering palliative treatment) was found to be comparable to initial treatment in men with a limited life expectance, either from advanced age or multiple comorbidities. Similarly, active surveillance (a technique employing intense monitoring with PSA testing, digital rectal exams, repeat biopsies and possible use of MRI or other biomarkers) was introduced with the goal of delaying treatment in some men with low risk cancer until the cancer becomes more aggressive and was shown to have similar outcomes to initial treatment in carefully selected men.

We wanted to study the trends in initial prostate cancer treatment in this context of recommendations for decreased screening and recognition of the feasibility of surveillance in certain patients with prostate cancer. What are the main findings?

Response: We found that the treatment rate in the overall Medicare population (all men who could potentially be screened for the disease) decreased substantially, by 42%. However, once men were diagnosed with prostate cancer, the decrease in treatment was less dramatic at only 8%. What should readers take away from this report?

Response:Our results indicated that both primary care physicians (who tend to perform the majority of PSA screening) and specialists (urologists, radiation oncologists and medical oncologists) who treat prostate cancer responded to the call to decrease overdiagnosis and overtreatment, but did so to differing degrees. The 42% decrease in treatment rates in the overall population leads us to think that PSA screening decreased significantly in response to the recommendations leading to far fewer men diagnosed that could ultimately be treated. Conversely, in seems that adoption of the surveillance strategies by treating specialists is more tempered. What recommendations do you have for future research as a result of this study?

Response: In order to increase use of surveillance, patients and doctors must feel assured that we can differentiate men with low risk disease from those with higher risk disease that is potentially fatal. This is an area where some uncertainty still exists and is a significant barrier to adoption of these surveillance strategies. We also recommend that medical policies aimed at increasing value in treatment should replace the current policies that reward volume. Is there anything else you would like to add:

Response: The only disclosure is that Dr. Hollenbeck is an Associate Editor for the journal Urology.

Sharp Decline In Prostate Cancer Treatment Among Men In The General Population, But Not Among Diagnosed Men
Tudor Borza , Samuel R. Kaufman,Vahakn B. Shahinian, Phyllis Yan, David C. Miller, Ted A. Skolarus and Brent K. Hollenbeck
doi: 10.1377/hlthaff.2016.0739 Health Aff January 2017 vol. 36 no. 1 108-115
Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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