Review Article

Changes in Patterns of Prostate Cancer Care inthe United States: Results of American College

of Surgeons Commission on CancerStudies, 1974–1993

Curtis Mettlin

Roswell Park Cancer Institute, Buffalo, New York

BACKGROUND. Advances in medical and public health practice have led to many changesin patterns of prostate cancer care. Data from several studies of prostate cancer by the Com-mission on Cancer of the American College of Surgeons provide information on the direc-tions, magnitudes, and consequences of these changes.METHODS. The Commission on Cancer conducts patient care evaluation (PCE) studiesbased on the voluntary participation of hospital cancer programs and their tumor registries.PCE studies have been conducted repeatedly for prostate cancer covering patients diagnosedas early as 1974 and as recently as 1990. In addition, the National Cancer Data Base of theCommission on Cancer collects data for all forms of cancer from throughout the country. TheCommission on Cancer, the American Cancer Society, and the American Urologic Associationalso has conducted a focused survey of radical prostatectomy outcomes. In aggregate, thesemultiple studies have accrued 179,366 reports on treatment of prostate cancer patients.RESULTS. Predominant among practice changes are new techniques of prostate cancer de-tection and initial evaluation which have led to shifts in disease stage at the time of initialtherapy. The proportion of prostate cancer that is localized at the time of detection hasincreased. Use of radiation therapy and radical prostatectomy has increased as the selectionof hormone treatment and no cancer-directed treatment have decreased. Five-year prostatecancer survival has improved for every stage of disease.CONCLUSIONS. The multiple studies by the Commission on Cancer provide data that arenot available from other sources. Continued monitoring of prostate cancer patterns of caremay be useful in measuring progress in control of this common disease. Prostate 32:221–226,1997. © 1997 Wiley-Liss, Inc.

KEY WORDS: prostate cancer; patterns of care; cancer treatment; staging, survival

INTRODUCTION

The number of prostate cancers diagnosed annuallyin the United States has increased markedly in recentyears. In 1988, there were an estimated 99,000 newcases of prostate cancer [1]. The number of new casesestimated for 1996 is 317,100 [2]. This represents anincrease of over 300% in less than a decade and isperhaps the most dramatic change in cancer incidenceto occur in this century. Much of this increase can beattributed to improved means of detecting tumorsearly that otherwise would have progressed to ad-vanced stage. Regardless of the reasons for the in-

crease, the changes are of such magnitude that theyhave important consequences for patterns of prostatecancer patient care. Changes in the treatment of pros-tate cancer have been the subject of several recentstudies and herein, the principal findings from theAmerican College of Surgeons Commission on CancerPatient Care Evaluation (PCE) studies, the NationalCancer Data Base (NCDB), and related special surveyswill be described. These data may provide an accurate

*Correspondence to: Dr. Curtis Mettlin, Roswell Park Cancer Insti-tute, Buffalo, NY 14263. E-mail: cmettlin@msn.comReceived 10 June 1996; Accepted 12 June 1996

The Prostate 32:221–226 (1997)

© 1997 Wiley-Liss, Inc.

depiction of the extent to which prostate cancer carehas changed in recent years and a benchmark againstwhich future developments may be measured.

OVERVIEW OF METHODOLOGIES

One of the objectives of the Commission on Cancerof the American College of Surgeons has been to de-velop criteria for cancer patient care related to diag-nosis, treatment, rehabilitation, and follow-up. To thisend, the Commission recommends that cancer com-mittees in hospitals regularly evaluate diagnostic pro-cedures, management, and end results, and assists inthis by organizing annual national surveys of specificcancer sites. Originally called patterns of care studies,PCE studies have been conducted for multiple tumortypes and repeatedly for prostate cancer covering pa-tients diagnosed as early as 1974 and as recently as1990. The methodology of these PCE studies has beendescribed in detail in earlier reports [3–7].

An additional resource, the NCDB is a joint projectof the Commission on Cancer of the American Collegeof Surgeons and the American Cancer Society. LikePCE studies, the NCDB is intended to facilitate com-munity, hospital, state, and national assessment of pa-tient care [8–11]. The NCDB annually collects data forall forms of cancer from throughout the country.These data are based on cases abstracted and comput-erized by hospital cancer registries. All submissionsare voluntary and data items collected include patientcharacteristics (i.e., age, race/ethnicity); tumor charac-teristics (i.e., grade and American Joint Commissionon Cancer [AJCC] stage group); first course of treat-ment (surgery, radiation, chemotherapy, hormone,and other); and follow-up (last contact date, vital sta-tus, and tumor status).

The Commission on Cancer also conducts specialsurveys of tumor registries when circumstances war-rant. In response to reports that the increased use of

radical prostatectomy was associated with high mor-bidity and mortality, the Commission on Cancer withthe American Cancer Society and the American Uro-logic Association conducted a focused survey of radi-cal prostatectomy outcomes [12]. In 1993, 484 institu-tions reported on the outcomes for 2,122 patients con-secutively treated by radical prostatectomy in 1990.Many of the data items requested were available fromthe tumor registry abstract or the medical chart but,for data items not ordinarily in the abstract, the reg-istrar was requested to query physicians and physi-cians’ office records. This follow-up procedure wasparticularly requested to describe the potency, conti-nence, and prostate-specific antigen (PSA) status ofpatients after treatment.

RESULTS

The numbers of patients and participating hospitalsin each of the different studies to be cited are summa-rized in Table I. The results of these studies have beenreported individually in detail in previous reports.Some data items were unique to particular studies.However, for other variables, information is availablefrom multiple studies, allowing analysis of trendsacross a two-decade interval.

Studies at Diagnosis

The initial evaluation of prostate cancer patients attime of diagnosis has changed in ways that have hadimportant implications for the manner in which pa-tients are staged and treated. The earliest PCE studiesdocumented the growing use of the radionuclide bonescan. Between 1974 and 1979, the proportion of newlydiagnosed patients receiving bone scans increasedfrom 21.5% to 59.3%. Even following that rapid rise,the utilization of this means of detecting metastaticspread of disease continued to increase, reaching

TABLE I. Numbers of Patients and Reporting Hospitals Included in AmericanCollege of Surgeons Commission on Cancer Prostate Cancer Patient

Care Studies

Study YearNo. of

patients studied

No. ofhospitalsreporting

PCE study [3–5] 1974 20,166 419PCE study [3–5] 1979 14,079 658PCE study [6] 1983 20,661 419PCE study [7] 1984 14,716 730PCE study [7] 1990 23,214 1,035Radical prostatectomy outcomes [12] 1990 2,122 484NCDB report [11] 1993 84,408 996

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72.2% of all patients surveyed for 1990. Simulta-neously, the data demonstrated a decline in the use ofbone roentgenograms, from 24.8% use in patients in1974 to only 11.6% in patients in 1990.

The more recent PCE studies have captured thechanging patterns of laboratory assessments per-formed at the time of diagnosis. Most notably, PSAwas measured in only 5.1% of patients in 1984 and by1990, this proportion had increased to 66.4%. Con-comitantly, use of serum acid phosphatase as a labo-ratory measure obtained at the time of diagnosis de-creased from 62.4% of patients in 1984 to 47.0% in1990.

Stage of Disease

The observation of changes in stage of disease atdiagnosis is confounded by changes in staging criteriaacross studies. In the earliest studies, all staging wasreported according to the American Urologic Associa-tion conventional A,B,C,D staging. In the more recentstudies, American Joint Commission on Cancer0,I,II,III,IV staging was reported [13]. Stages A and Bor 0,I, and II represent localized disease, stages C or IIIrepresent regional spread, and stage D or IV reflectsmetastatic spread. The distribution of stage of diseaseand the trend from 1974 to 1983 are shown in Table II.Similar information for the 1984–1993 interval isshown in Figure 1. These staging results reflect patho-logic stage if surgery was performed.

Between 1974 and 1979 there was an apparent in-crease in the proportion of cancers having distantspread at the time of diagnosis, from 23.7% stage D in1974 to 27.1% in 1979. There also was an apparentdecrease in stage C disease, from 19.5% in 1974 to15.6% in 1979. The greatest overall change in stage,however, occurred between the 1984 and 1993 studies.The proportion of AJCC stage II tumors increased al-most two-fold to represent nearly half of all prostatecancers diagnosed in 1993, from 25.6% in 1984 to48.6% in 1993.

Trends in Treatment

The trends in selection of radiation, prostatectomy,hormone treatment (medication or orchiectomy), and

no cancer-directed treatment as the initial pattern ofcare are shown in Figure 2. Use of radiation treatment(predominantly external beam but including intersti-tial) showed early increases rising from 5.5% of allpatients in 1974 to 12.9% in 1979, 21.1% in 1983, 22.9%in 1984, 22.6% in 1990, and 30.1% in 1993. The com-parable proportions for prostatectomy were 9.2%,8.6%, 7.0%, 8.9%, 21.5%, and 29.2%. Hormone treat-ment decreased from 49.4% to 34.2%, to 29.6%, to24.1%, to 19.5%, and finally to 11.0% in 1993. The pat-tern of selection of no cancer-directed treatmentshowed an early increase from 23.6% in 1974 to 33.2%in 1979, 33.2% in 1983, and 36.2% in 1984. This wasfollowed by a decrease to 28.8% in 1990 and 21.6% in1993. Not shown are trends for combinations of treat-ment which were employed relatively infrequentlythroughout.

Table III reports the proportions of patients withlocalized prostate cancer treated by radical prostatec-tomy in 1990 according to patient age and region fromthe NCDB. Patients younger than 55 were approxi-mately seven times more likely to receive radical pros-tatectomy compared to patients 75–79 (69.1% vs.10.8%). The proportion of patients treated by radicalprostatectomy varied by region. In 1990, the Pacificregion contributing hospitals reported the highest pro-portion of localized prostate cancer patients treated byradical prostatectomy (35.4%) and the lowest use wasreported from hospitals in the New England and Mid-Atlantic regions (21.5% and 20.1%).

Radical Prostatectomy Outcomes

The special study of radical prostatectomy revealedthat 15 of 2,122 patients were reported to have died asa result of the operation. The operative mortality rateamong patients with outcome reported was 0.7%. Po-tency status was reported for 1,266 patients. Of these,207 were reported impotent before surgery was per-formed. Among the remaining 1,059, 599 (56.6%) were

TABLE II. Trends in Distribution of Prostate CancerStage of Disease at Diagnosis, 1974–1983

Stage 1973 (%) 1979 (%) 1983 (%)

A 22.9 27.1 29.4B 33.8 30.2 30.1C 19.5 15.6 13.3D 23.7 27.1 26.5

Fig. 1. Trends in prostate cancer stage of disease, 1984–1993.

Prostate Cancer Patterns of Care 223

incapable of erection, 307 (29.0%) had partial erectilepotency, and 153 (14.4%) were reported to be fullypotent. Complete control or only occasional urinarycontinence requiring no pads was reported for a totalof 1,458 patients (81.3%) of the 1,796 previously con-tinent patients with known continence status at fol-low-up. For only 65 patients (3.6%) was total inconti-nence reported.

Trends in Survival

The 1979 PCE study examined the 5-year survivalof patients diagnosed in 1974. Similarly, the 1983 and1990 studies examined the long-term survival of pa-tients diagnosed in 1978 and 1984, respectively. The

stage-specific 5-year survival rates for these severalpoints in time are summarized in Table IV. The datashow a pattern of survival improvement in all stagesacross the interval covered.

DISCUSSION

As clinical research progresses, there is a parallelprocess of promoting the application of emerging con-cepts to patient care at the community level. Unfortu-nately, there are few sources of information by whichto judge the extent to which the patients receive wide-spread benefit from advances in cancer care. Trends inincidence and mortality may be observed using popu-lation-based cancer registries, but these registries havemore limited usefulness when the focus is on moni-toring translation of clinical research advances to thecommunity level. For these topics, investigators turnto other resources such as health insurance databasesor pooled data from multiple hospital-based registries.

In the case of prostate cancer, multiple data sourceshave been studied to document trends in patterns ofcare. In addition to the Commission on Cancer studiescited herein, the changing patterns of radiationtherapy for prostate cancer patients have been studiedby the American College of Radiology in patterns ofcare studies [14,15]. Medicare records have been stud-ied by Lu-Yao and colleagues [16,17] and Mark [18] toassess utilization and outcomes of radical prostatec-tomy. Potosky and colleagues [19] have used the sameresources to study the relationship between rising in-cidence and increased use of PSA and ultrasound.

Several advantages adhere to detailed analysis ofnational patient care databases. By considering the ex-perience of many physicians at many institutions witha large number of patients at a given point in time,effects of treatment, disease stage, or institutional set-ting may be distinguished from the effects of a physi-cian’s skill, the peculiarities of an individual’s disease,or the facilities of a single institution. The large num-ber and national distribution of institutions participat-ing may better reflect the broad experience of different

Fig. 2. Trends in initial treatment modality for prostate cancerpatients in the United States, 1974–1993.

TABLE III. Proportion of Localized Prostate CancerPatients Treated by Prostatectomy by Age at Diagnosis

and Region

Age Percent Regiona Percent

<55 69.1 New England 21.555–59 58.9 Mid-Atlantic 20.160–64 53.9 South Atlantic 30.465–69 46.3 East North Central 29.970–74 28.8 East South Central 32.675–79 10.5 West North Central 30.380+ 1.8 West South Central 30.3

Mountain 29.5Pacific 35.4

aNortheast: Maine, Vermont, New Hampshire, Massachusetts,Rhode Island, Connecticut, New York, Pennsylvania, New Jer-sey; Southeast (South Atlantic): Delaware, District of Columbia,Maryland, West Virginia, Virginia, North Carolina, South Caro-lina, Georgia, Florida; Midwest: Wisconsin, Michigan, Illinois,Indiana, Ohio, Minnesota, North Dakota, South Dakota, Iowa,Nebraska, Kansas, Missouri; South: Kentucky, Tennessee, Mis-sissippi, Alabama, Oklahoma, Arkansas, Texas, Louisiana;Mountain: Montana, Idaho, Wyoming, Nevada, Utah, Colorado,Arizona, New Mexico; Pacific: Washington, Oregon, California,Alaska, and Hawaii.

TABLE IV. Trends in Stage-Specific 5-Year ProstateCancer Survival, 1974–1984

AUAstagea 1973 (%) 1978 (%)

AJCCstage 1984 (%)

0 90.8A 77.7 85.0 I 84.6B 68.1 77.0 II 79.6C 57.8 65.5 III 71.1D 23.0 30.0 IV 32.3

aAUA, American Urologic Association.

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hospitals and clinics treating patients. National data-bases also may be helpful in evaluating diffusechanges that may be imperceptible in single institu-tion series.

The studies from the Commission on Cancer of theAmerican College of Surgeons may be particularlyuseful because of their repeated nature and the longi-tudinal perspective they provide. These data also havethe advantages of detailed information on the extentof disease, diagnostic modalities employed, and de-tailed information on types of surgery, chemotherapy,or radiotherapy applied, and patient survival. Finally,these data have a cost advantage in that they are vol-unteered by tumor registrars and cancer committeesin the American College of Surgeons network of affil-iated cancer programs.

There are, however, important limitations to thesetypes of data. Although a very large number of insti-tutions participate, not all hospitals contribute dataand different numbers of hospitals participate at dif-ferent times. The number of participating NCDB hos-pitals has increased markedly between 1985 and 1993.This increase parallels and reflects the increase of com-puterized hospital cancer registries over that time pe-riod. Most data are received from hospitals with acomputerized cancer registry, possibly introducinghospital selection bias. Furthermore, the data may ad-equately represent hospital-based care, but do not ascomprehensively cover outpatient treatment.

A further limitation is that investigators using thesedata must rely on the hospital cancer committee or itsequivalent to supervise the quality control of casefinding and abstracting. Internal reviews of abstractsby registry staff, hospital-based computer data edits,and similar local measures may enhance data qualitybut it is not possible or cost-effective to audit all datasubmissions independently. When quality control as-sessments have been conducted, however, the resultssuggest high levels of reproducibility of results [20,21].

These limitations of the data notwithstanding, themultiple studies of prostate cancer patient care in theUnited States may document profound changes inurologic oncology practice in the relatively short in-terval. Although much of the recent change appearsrelated to increased early detection, the first studiesshowed apparent increases in advanced disease. Theincrease in the proportion of patients stage D at diag-nosis between 1974 and 1979 is consistent with theincreased use of bone scans which could reveal me-tastases to the bone which had previously gone unde-tected. That the rise in stage D decreased as the rise ofbone scanning tapered off further suggests a relation-ship between the two. After 1984 there was a substan-tial increase in the proportion of prostate cancers di-agnosed at localized stage with reductions in both ad-

vanced disease and the earliest, possibly clinicallyinsignificant tumors. These trends are consistent withthe effects to be expected from widespread use of PSAtesting in the population and are less reliant on trans-urethal resection of the prostate (TURP) for early de-tection. TURP was formerly the principal means ofdetection for nonpalpable cancers in asymptomaticmen. More recently, PSA is responsible for greater de-tection in asymptomatic men.

Significant among many changes in treatment is theincrease in use of radiation therapy after 1974 and asubsequent increase in use of radical prostatectomyafter 1984. Throughout the last two decades there hasbeen a decrease in the use of hormone therapy and theselection of no cancer-directed treatment. Despitethese general trends, a range of treatments, includingno treatment, continue to be widely accepted as anappropriate first course of therapy for prostate cancer.That a range of treatment options fall within the ap-parent normative standards of care for prostate cancermay reflect differences in views regarding optimaltreatment as well as the role of factors such as the ageof the patient or grade of disease in guiding treatmentselection.

Prostate cancer survival appears to have improvedat every stage of disease. Although the progress isincremental, prostate cancer is now the most commoncancer other than skin cancer in the United States andeven small improvements in outcome can translateinto significant numbers of years of life saved.

Improved early detection, wider application of pro-cedures predictive of metastases, greater use of cura-tive treatment, and other trends observed in these sur-veys all have potential impact on mortality patterns ofpatients with prostate cancer. They are all indicative ofa changing pattern of care for cancer patients in theUnited States and deserve continued observation andevaluation.

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