Medical and non-medical determinants of prostate cancer management: a population-based study
Introduction
Prostate cancer is the most frequently diagnosed cancer among men in developed countries. In most European countries, the incidence of prostate cancer has risen more than that of any other cancer over the past two decades, mainly due to the increasing use of prostate-specific antigen (PSA) testing and ultrasonography. In France, crude incidence was estimated at 93.7 per 100 000 person-years in 1995 [1] (age-standardised rate using the world population as a standard: 54.4/100 000). Although prostate cancer can be screened for by PSA testing, the optimal management of the disease is still controversial [2].
Strategies for treatment of prostate carcinoma show variation not only between different countries, but also from one region to another within a given country 3, 4. Treatment efficacy can only be assessed through randomised clinical trials using large series. Such studies are underway, but their results will not be available for several years [5]. In the interim, we have to rely on observational or registry studies to evaluate the results of prostate carcinoma care.
In the French population, non-medical determinants of the variation of treatment choices in prostate cancer are not very well understood. We carried out a population-based study to obtain information on practice patterns in prostate cancer management during 1995 in five French cancer registries. We also aimed to reveal any variations between the regions and sectors by the unbiased evaluation of treatment practices in France.
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Population
Our study population consisted of 1000 men with a prostate neoplasm diagnosed during 1995 in five of the eight French cancer registries covering the following administrative areas: Bas-Rhin, Calvados, Haut-Rhin, Isère and Tarn. A sample of 200 randomly selected cases from the database of each registry was considered to be representative of the number of prostate cancers diagnosed annually in these regions. Definitive analysis concerned only 991 patients as nine cases were excluded because the
Results
In Table 1, areas of residence are compared according to medical and non-medical criteria. Incidence changed very little from one area to another, whereas the standardised mortality rate (using the world population as a standard) varied from 12.3 to 19.2/100 000 inhabitants per year. Age at diagnosis did not differ between the various administrative areas, although variations existed in the PSA level, Gleason score and clinical stage at diagnosis (the Haut-Rhin area had a higher incidence of
Discussion
A preliminary investigation in four French administrative regions enabled us to define the principal characteristics of our cohort and to establish the medical factors determining the initial treatment carried out [7].
The initial treatment received by our cohort, for all disease stages, was curative in 39% of cases (surgical 21%, local radiotherapy 18%) and non-curative in 61%. There are large differences from one country to another; in the United States 62% of patients have received curative
Conclusions
We found that in France, as in other developed countries, the initial treatment of prostate cancer varies considerably according to geographical criteria and the healthcare sector.
This is the first study based on population data carried out in this country. It is now of fundamental importance to collect data on 5-year survival and recurrence rates in these patients to find out whether this disparity leads to unequal chances of survival from one area or one healthcare sector to another. While
Acknowledgements
This survey was supported by the Délégation Régionale de la Recherche Clinique de Toulouse (grant number 0105102), INSERM (grant number 4M606C) and the Groupe de Recherche de l'Institut Claudius Régaud. The authors thank Mrs. Nina Crowte for translation of the paper.
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