Prostate cancer radiotherapy
Integrated prostate cancer centers might cause an overutilization of radiotherapy for low-risk prostate cancer: A comparison of treatment trends in the United States and Germany from 2004 to 2011

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Abstract

Introduction

Aim of the study was to analyze changes in primary treatment for low-risk prostate cancer across different healthcare systems.

Materials and methods

We compared “Surveillance Epidemiology and End Results” data (USA) with data from four German federal epidemiological cancer registries, both from 2004 to 2011. We excluded metastatic disease and patients aged ⩾80 years. Thereof, we identified 132,506 (USA) and 54,159 (Germany) patients with low-risk according to the 2014 EAU guidelines. We tested treatment trends for statistical significance with a linear regression model.

Results

Active treatment was radical prostatectomy (RP) in 36.1% vs. 66.2% and radiotherapy (RT) in 38.4% vs. 11.8%. No active treatment (NAT) was reported in 24.2% vs. 16.2% (p < 0.001 each). Through the study period the use of RP decreased from 37.1% to 34.2% in the USA (p = 0.04) and was constant at a mean of 66.2% in Germany (p = 0.8). The use of RT in the USA decreased from 42.8% to 31.8% (p < 0.001), while it was stable in Germany (p = 0.09). The NAT group grew from 18.0% to 33.2% in the USA (p < 0.001), while it was stable in Germany until 2009 (p = 0.3). From 2009 to 2011 there also was an increase of the NAT group in Germany from 15.2% to 19.4% (p = 0.001).

Conclusion

In contrast to former evidence we found the relative use of RT for low-risk prostate cancer much higher in the USA compared to Germany. The implementation of integrated prostate cancer centers in the USA might explain this observation. Deferred and defensive treatment strategies showed a steady increase in the USA. This development seems delayed in Germany by several years.

Section snippets

Materials and methods

To compare treatment trends over time we analyzed population based data from the USA and Germany covering the years 2004–2011. Exclusion criteria were metastatic prostate cancer and age ⩾80 years.

We derived US data from the “Surveillance Epidemiology and End Results” (SEER) program. Within this initiative the “National Cancer Institute” collects information about the incidence and the survival of oncological diseases. The SEER database is widely used for population-based cancer research [7], [8]

Results

The total share of low risk prostate cancer was 34.5% (132,506/384,117) in the USA and 40.4% (54,159/134,083) in Germany (p < 0.001). Fig. 1 shows the yearly share of low risk prostate cancer from 2004 to 2011. There was a declining trend both in the USA (p = 0.002) and in Germany (p = 0.005).

Within the entire study period treatment for low risk prostate cancer differed largely between the USA and Germany: Treatment was RP in 36.1% vs. 66.2%, RT in 38.4% vs. 11.8%, and both in 1.3% vs. 5.8% (p < 0.001

Discussion

By comparing population based cancer registry data from the USA and Germany we found notably divergent treatment habits for low-risk prostate cancer. In the USA RT was the major treatment option at the beginning of the study period, but its use declined to the benefit of NAT. Therefore, deferred and defensive treatment strategies showed a steady increase. In Germany RP was the major treatment option with no relevant change of treatment habits over time. However, from 2009 to 2011 the use of

Conclusion

The relative use of RT for low-risk prostate cancer was much higher in the USA compared to Germany. The implementation of integrated prostate cancer centers in the USA where urologists acquire a share of the radiation therapy facility might explain this observation. The higher use of RT was about threefold in 2004 and came down to the double proportion in 2011. Deferred and defensive treatment strategies showed a steady increase in the USA reflecting changes in clinical guidelines. Compared to

Conflict of interest statement

There is no conflict of interest.

Funding

None.

Acknowledgment

We thank Professor Rainer Koch for statistical advice. Parts of this study were presented at the Annual Meetings of the American Urological Association and the European Association of Urology in 2014.

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