A REPORT ON PRACTICE PATTERN TRENDS IN PROSTATE CANCER

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1 A REPORT ON PRACTICE PATTERN TRENDS IN PROSTATE CANCER Date presented to Cancer Committee: September 12, 201 By: Ian Thompson, MD Data by: Shelly Smits, RHIT, CCS, CTR INTRODUCTION: There have been abundant recent articles and policy directives which are advocating both a recommendation to not perform PSA screening, and also a recommendation to move most newly diagnosed patients to expectant observation instead of definitive treatment. The penetration of these recommendations has been fairly recent and increasingly persuasive to many health care providers. There has been a subjective impression among Urologists and Radiation Oncologists that these two recommendations have decreased both the number of patients diagnosed with, and also the number of patients who are diagnosed with being treated with surgery or radiation. Because these recommendations are fairly recent, it was decided the look at the most recent information available to the Cancer Registry and compare it to the same time periods from the previous years. METHOD: At the time this study was started, only the first 7 months of 2012 had been accessioned into the PeaceHealth Cancer Registry. As a result, to get a timely first impression, this data was first obtained for the first 7 months of 2012, and compared to the same data for the first 7 months of 2009, 20, and Subsequently, this data was also compared to the annual information from the years 2007 through 2012 once all prostate cases had been abstracted (June 201). Total numbers of patients, age, PSAs, Gleason Scores, and Stage of those patients, as well as management for those patients were obtained from the Registry.

2 FINDINGS: TABLE 1 Year Total for entire Year There is a marked steady decline in the yearly number of s diagnosed from 2007 through 2012 confirming this as probable a real finding. Because PSA screening is the most common way a prostate cancer is diagnosed, it is most likely a valid assumption to assume there was also a drop off in PSA screening utilization. Men over the age of 80 is one target group for which PSA screening has been strongly discouraged. TABLE 2 Comparing each year ( ) Age average median Range total cases % over % % % % % % There was no change in the average, or median age of newly diagnosed patients. In looking at the patients over 80 years of age, there has been a drop off in the percent of patients over the age of 80 in the local population, also implying less

3 PSA screening in this age group consistent with the general recommendations of a cut off to screening at an elderly age. TABLE Comparing each year ( ) PSA value average median range total w/psa done The average PSA was significantly skewed by the higher numbers of a few patients. But the median number is essentially unchanged over the years studied. TABLE 4 Comparing each year ( ) Gleason score average median range Total w/gleason to to to to to to 112 The average and median Gleason Score remained constant throughout the time period.

4 T2 (all) % T1c % Total Unknown T4 Tb Ta T T2c T2b T2a T2 T1c T1b T1a T1 TABLE 5a & b (Entire Year) Clinical T Stage Clinical Stage Group Total (0.9%) 166 (77%) 8 (.7%) 7(.2%) 2(14.9%) (0.5%) 179(87.7%) 7(.4%) (4.9%) 7(.4%) (4%) 141(81%) 5(2.9%) 1(7.5%) 8(4.6%) (2.6%) 80(54.4%) 6(4.1%) 11(7.5%) 2(1.4%) (5.8%) 80(50.%) 4(2.5%) 1(8.2%) 5(.1%) (2.47%) 58(49.57%) 6(5.12%) 12(.25%) (2.56%) 117 Except for the aberrant year of 2008, the T stage of the cancer at the time of diagnosis has not appreciably changed over the time period. The definitions of Staging Group did change in the registry in 20 which explains the difference between pre and post 20 data in the Clinical Stage Group data. There does seem to consistently be a predominance of T1c (clinically unapparent tumors) cancers throughout the years. There may be a possible increase in the number of advanced metastatic patients at diagnosis especially in the year 2012.

5 Other Horm alone Rad Surg Surveillence Total cases Other Horm alone Rad Surg Surveillence ACTIVE SURVEILLENCE: The recommendation to offer less definitive treatment over time would be reflected in the overall treatment tables below, For simplicity, all patients who underwent a prostatectomy, and all patients who had radiation with the exception of those patients receiving adjuvant radiation post prostatectomy were listed as either receiving surgery or radiation. TABLE 6a Comparing 1st 7 mo of each yr ( ) Treatment done (26%) 22 (27%) 20 (2%) 14 (19%) 52 (46%) (41%) 4 (9%) 5 (47%) 24 (21%) 18 (22%) 25 (29%) 15 (20%) (%) 5 (6%) 5 (6%) 8 (11%) 5 (4%) (4%) (%) (4%) TABLE 6b, Stage I-III only Diagnosed at St. Joseph Treatment done (24%) 86 (54%) (21%) 2 (1%) (24%) 70 (5%) 29 (22%) 1 (1%) (0%) 67 (46%) 0 (21%) 4 (%) (27%) 48 (47%) 2 (22%) 2 (2%) 2 (2%) At first glance it appears that there has been a trend toward a decrease over the time period in the number of patients entering Surveillance with a stable number

6 of patients receiving radical prostatectomy, and a stable number of patients receiving radiation. Hormonal therapy alone has increased although there has not been a reciprocal increase in advanced cancer patients. However, this finding is due to the increase in the number of metastatic at diagnosis patients. However, when looking only at localized disease patients, there has been no change at all in the percent of patients receiving observation or any of the definitive treatments. Preliminary Impressions: There were two separate recommendations that have entered into the stream of thinking over the past few years; first the recommendation to not routinely screen every adult male over the age of 50, and the second, later recommendation which was to not treat as many newly diagnosed patients and move many patients toward observation alone. In this community, it is apparent that the recommendation to not do routine PSA screening had some penetration with a noticeable decrease in the numbers of diagnoses over that past few years. However, it is reassuring that this decrease in PSA screening did not result in higher PSA levels or Gleason Scores at the time of diagnosis. However, there was a trend to more patients diagnosed with metastatic disease, which is consistent with some of the literature reports. In this community, it is apparent that the recommendation to not provide definitive treatment to increasing numbers of newly diagnosed patients had no penetration in how s were managed. The percentages of patients receiving surveillance, surgery, or radiation remained the same. The use of hormonal intervention increased, but as a direct result of the increase in metastatic disease.

7 Summary: There has been a decrease in the number of diagnosed over the past few years. This may be in response to the recommendation of various national societies to not perform routine PSA screenings. This has resulted in the diagnosis of more advanced cancers, which according to some groups is acceptable, since overall survival is the same in screened populations to unscreened populations according to some large international studies. However, the recent recommendation that many patients with newly diagnosed localized prostate cancer do not need definitive treatment has not resulted in any change in the number of patients who enter a surveillance only intervention