Prostate Cancer Treatment Rates Drop Following Changes in Screening Recommendations

Tudor Borza, MD

A sharp decline has been observed in the overall rate of men receiving treatment for prostate cancer, according to the results of a study published in Health Affairs.

This decline is potentially attributed to recent changes in guideline recommendations that suggest that there is widespread overdiagnosis and overtreatment in the prostate cancer treatment paradigm.

The study found that population-based treatment rates declined by 42%, while rates among diagnosed men declined by only 8%.

“It was surprising to see such a big decrease,” said study author Tudor Borza, MD. “We didn’t know how much of an uptick there would be by primary care doctors in terms of decreasing their PSA screening and how that would translate to men getting treated.”

OncLive: What was the rationale for collecting these data about men with prostate cancer?

In an interview with OncLive, Borza, a urologic oncology and health services research fellow at Michigan Medicine, discusses the major findings of his study and his stance on the importance of prostate cancer screening and treatment.Borza: We wanted to look at this particular rate of treatment because, over the last decade or so, there have been many changes in the recommendations for prostate cancer screening and the way that men with prostate cancer are treated. In our paper, we looked at the changes in national screening recommendations made by the US Preventive Services Task Force. which, in 2009, recommended against screening for prostate cancer in men older than 75. And then in late 2011/early 2012, they recommended against all PSA screenings for prostate cancer, saying that the harms from screening were greater than the harms from treatment. Obviously, there’s a lot of press that surrounded that decision, and many physicians changed the way they practice medicine because of that.

Similarly, professional organizations that guide how specialists do their jobs, like the American Urological Association (AUA), and the NCCN, also changed their screening recommendations, though not to the same degree. Most specialists and national organizations still recommend PSA screening, now in different groups of men, but they still recommend that it be done.

At the same time, because of the known overdiagnosis and overtreatment of prostate cancer, specialists started to use surveillance strategies—either watchful waiting for men who don’t have a long life expectancy, or active surveillance for men with low-risk prostate cancer. Both of these have been shown to be as effective as upfront treatment. We’ve started using these surveillance strategies with the goal of avoiding unnecessary treatment in some of these men.

What were the most significant findings from your study?

All of these things were happening over the period of time that we conducted our study. We wanted to get an idea of what the effect was on treatment from this overall change in thinking, and really try to tease out whether the screening recommendations or the use of surveillance had more of an impact on the treatment rates.We looked at the treatment rates in the population as a whole—that’s all men who could possibly be screened for prostate cancer in our Medicare sample. We found that that treatment rate decreased by 42%. It went from 4.3 per 1000 men to 2.5 per 1000 men getting treated, and that’s a big drop.

Were these results surprising to you in any way?

Where do you stand in terms of all the controversy surrounding PSA screening?

When we looked at just the men who were already diagnosed, that decrease was only 8%—from 718 to 659 men per 1000 patients getting treated. A lot of people infer that the screening recommendations had a big impact on how many men get diagnosed and then how many men can potentially be treated. The use of surveillance had only a minor impact on that overall decrease in treatment rates.We didn’t really have a good understanding of what the screening recommendations would do to treatment. It was surprising to see such a big decrease. We didn’t know how much of an uptick there would be by primary care doctors in terms of decreasing their PSA screening and how that would translate to men getting treated. A 42% decrease was certainly surprising.Yes, there’s definitely a lot of controversy. I’m a urologist; we see men who often have significant disease that is going to be fatal, and in that context, not screening anyone for prostate cancer doesn’t seem to make sense to us. We know that, when PSA was introduced in the early 1990s, the incidence of metastatic disease at diagnosis of prostate cancer plummeted. So we know there is a benefit to this. But obviously, there’s plenty of overdiagnosis and overtreatment—diagnosing men who would never be symptomatic or treating men who don’t need treatment.

Are there any next steps planned following the results of your study?

What progress would you like to see in this treatment landscape in the next 5 to 10 years?

There is a middle ground here, and I think that middle ground is what the AUA guidelines recommend, that for men who we know are at a higher risk, having a discussion about what it means to have a PSA screening test and how that could potentially lead to a downstream biopsy and diagnosis of prostate cancer that may require treatment—having that conversation with a patient, and making sure they understand prior to ordering the PSA test, this is best practice, and really having the patient involved in that decision, not just making a decision as a physician alone. That is probably the best way to do it.There are a couple next steps. Our study ended in 2012, and we now have an additional year of data, so we’ll be seeing how that trend continues and if there is a continued increase in the use of surveillance—which we expect there will be based on some other research. There are other investigators within our group that are using collaborative data, (not Medicare data, but data pooled from all the urologists in the state) looking at the use of active surveillance, which allows a different look than we’re able to do using just Medicare data and seeing what the rates of surveillance are, and how surveillance is done, and really talking with the treating urologist and figuring out what the barriers are to the use of surveillance and how we can overcome those to increase the use of active surveillance in men with low-risk disease or increase the use of watchful waiting in men who have a very limited life expectancy.I think in the next 5 years, we’re going to get much better at risk-stratifying men—that is, figuring out which men with prostate cancer are going to be at highest risk of developing metastatic disease and dying, and that’s through the use of new tissue biomarkers as well as the advance of prostate MRI. A better way of figuring out who these high-risk patients are will allow us to provide them with more aggressive treatment upfront, so they’re the ones that are most likely to benefit. And on the flip side, it’ll allow us to spare some men who aren’t going to ever have a problem from prostate cancer from treatment. I’d like to see us push that envelope of really identifying who’s at highest and lowest risk. That’s going to allow us to provide much more accurate, tailored treatment strategies in the future.

Borza T, Kaufman SR, Shahinian VB, et al. Sharp decline in prostate cancer treatment among men in the general population, but not among diagnosed men. Health Affairs. 36,
NO. 1 (2017): 108—115. doi: 10.1377/hlthaff.2016.0739.