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Authors Lo J, Papa N, Bolton DM, Murphy D, Lawrentschuk N
Review Date January 2016
Citation Prostate Int 2015 (in press); http://dx.doi.org/10.1016/j.prnil.2015.11.001
Widespread PSA testing for prostate cancer (PCa) over the past decade or so has led to concerns about over-diagnosis and over-treatment. To ameliorate some of these risks, there have been changes to the way men with PCa, particularly low-risk PCa, are treated, with greater emphasis on active surveillance and less on curative treatments. Despite this trend, however, many men continue to have some form of curative treatment and there appears to be a growing perception among multidisciplinary clinicians that more aggressive treatments such as high dose rate (HDR) brachytherapy are being favoured. It is also possible that use of pelvic lymph node dissection (PLND) may be increasing given its accuracy and reliability in staging metastatic disease.
This Australian study aimed to examine temporal trends in PCa care, particularly current rates of screening and aggressive interventions (HDR brachytherapy and PLND).
Health services data from the Australian Medicare Benefits Schedule (MBS) website were used to assess Australian men undergoing PCa screening and treatment from 2001 to 2014. HDR brachytherapy was first listed as an MBS item in 2007. For comparison, data on low dose rate (LDR) brachytherapy was compared with HDR brachytherapy only from 2007, even though it has been recorded as an MBS item since 2001. Radical prostatectomy (RP) with PLND has a different item number to RP without PLND. External beam radiotherapy was not recorded consistently or comprehensively over the time period and was not included in this analysis.
Age-specific rates of PSA screening were calculated from 2001 to 2014. Mean 7-year (2001-2007, 2008-2014) ratios of RP with PLND compared to RP without PLND and ratios of HDR to LDR brachytherapy (from 2007 only) were determined by state jurisdictions.
Rates of PSA testing were highest for men aged 65-74 years followed by men aged 55-64 years. Even though rates were lower in older men, still more than 15,000/100,000 tests were done in 75-84 year-old men and over 8,000/100,000 men aged 85 years or older annually. From 2008, the rate of PSA screening trended downward significantly by year for each age group (P < 0.02) except for men aged 85 years or older (P = 0.56).
The ratio of RP with PLND to RP without PLND over 2008 to 2014 (mean ratio = 1.1) was lower than for 2001 to 2007 (mean ratio=1.9) across all states and territories suggesting that PLND rates had decreased. From 2008 to 2014, PLND was performed at least 2.7 times more frequently in New South Wales and the Australian Capital Territory than in other jurisdictions.
Since 2007, brachytherapy practice across Australia has evolved towards a relatively low use of HDR brachytherapy (ratio of HDR to LDR brachytherapy < 0.5 for all jurisdictions except the Australian Capital Territory with a much higher ratio or HDR:LDR than other jurisdictions).
Rates of PLND and HDR brachytherapy for PCa have declined in Australia, providing evidence for the effect of stage migration due to widespread PSA screening. However, the reasons for the differences in rates of use of these procedures between jurisdictions cannot be ascertained from this study Currently, PSA screening rates remain high among older men, which may expose them to unnecessary investigations and treatment-related morbidity. The results of this study have limitations due to being based on health services data alone. Registry studies that include details of patient characteristics, and studies of decision-making of patients and health professionals/multidisciplinary teams with respect to PSA testing and PCa treatments would help to explain the results seen here.
Points to Note
- This Australian study based on health services data (Medicare) showed a considerable decline in PLND and HDR brachytherapy rates in Australia between 2001 and 2014, perhaps reflecting stage migration due to widespread PSA testing and improved risk stratification before treatment.
- Some differences between jurisdictions in the use of HDR brachytherapy were observed but the reasons are unknown.
- Limitations of using health services data include: lack of information about patients characteristics, no information about the use of active surveillance, combination therapies are not recorded as such, type of RP is not recorded, and it was not known how many PSA tests were in men with some suspicion of having PCa; however, this was estimated to be a small proportion of all PSA tests.
- The rated of PSA testing have declined over the study period, possibly reflecting guidelines indicating that PSA should not be used as a population screening test. However, many older men for whom a PSA test is unlikely to have any benefit are still undergoing testing.
- The data presented here suggest further research is warranted to understand patient and clinical decision-making that underpins the observed trends in PSA testing and PCa treatments.