Declining use of brachytherapy for the treatment of prostate cancer

doi:10.1016/j.brachy.2013.08.005

Brachytherapy

Volume 13, Issue 2, March–April 2014, Pages 157-162

https://doi.org/10.1016/j.brachy.2013.08.005 Get rights and content

Abstract

Purpose

To analyze the recent trends in the utilization of external beam radiation therapy (EBRT) and brachytherapy (BT) for the treatment of prostate cancer.

Methods and Materials

Using the Surveillance, Epidemiology, and End Results (SEER) database, information was obtained for all patients diagnosed with localized prostate adenocarcinoma between 2004 and 2009 who were treated with radiation as local therapy. We evaluated the utilization of BT, EBRT, and combination BT + EBRT by the year of diagnosis and performed a multivariable analysis to determine the predictors of BT as treatment choice.

Results

Between 2004 and 2009, EBRT monotherapy use increased from 55.8% to 62.0%, whereas all BT use correspondingly decreased from 44.2% to 38.0% (BT-only use decreased from 30.4% to 25.6%, whereas BT + EBRT use decreased from 13.8% to 12.3%). The decline of BT utilization differed by patient race, SEER registry, median county income, and National Comprehensive Cancer Network risk categorization (all p < 0.001), but not by patient age (p = 0.763) or marital status (p = 0.193). Multivariable analysis found that age, race, marital status, SEER registry, median county income, and National Comprehensive Cancer Network risk category were independent predictors of BT as treatment choice (all p < 0.001). Moreover, after controlling for all available patient and tumor characteristics, there was decreasing utilization of BT with increasing year of diagnosis (odds ratio for BT = 0.920, 95% confidence interval: 0.911–0.929, p < 0.001).

Conclusions

Our analysis reveals decreasing utilization of BT for prostate cancer. This finding has significant implications in terms of national health care expenditure.

Introduction

Patients diagnosed with prostate cancer have a number of management options available to them and, in certain situations, deferring treatment altogether may be recommended (1). Historically, the major forms of treatment include surgical management and radiation therapy, which includes external beam radiation therapy (EBRT) and brachytherapy (BT). The development of the ultrasound-guided, transperineal technique in the 1980s led to the rapid adoption of BT for the treatment of prostate cancer a decade later. As a result, previous patterns of care analyses had demonstrated increasing use of BT relative to EBRT [2], [3], [4], [5], [6], [7]. Over the past decade, however, we have witnessed the development of sophisticated EBRT techniques, such as intensity-modulated radiation therapy (IMRT) that, within a short period of time, have replaced the use of conventional EBRT for the treatment of prostate cancer [8], [9]. Whether the proliferation of these novel EBRT techniques has impacted the utilization of BT has not previously been demonstrated.

The Surveillance, Epidemiology, and End Results (SEER) database is a cancer registry overseen by the National Cancer Institute that collects information regarding patient demographics, tumor characteristics, treatment course, and patient survival from approximately 26% of the U.S. population (10). One of its many roles is to allow for assessment of national patterns of cancer care. Using the SEER database, we sought to analyze recent trends in the utilization of EBRT and BT for the treatment of prostate cancer.

Section snippets

Methods and materials

The SEER database (“SEER 18 Regs Research Data +Hurricane Katrina Impacted Louisiana Cases, Nov 2011 Sub [1973–2009 varying]”) was queried using SEER*Stat software, version 7.1.0 to identify men aged 20 years and older diagnosed with locoregionally confined, microscopically confirmed prostate adenocarcinoma (ICD-O-3 morphology code 8140) between 2004 and 2009 (the most recent data available at the time of our analysis). This specific time period was chosen given the limitations of the SEER

Results

A total of 182,123 men were included in our analysis. The number of patients diagnosed, treated with surgery, and treated with radiation therapy are summarized in Fig. 1. As can be seen, the number of patients diagnosed with prostate adenocarcinoma reached a peak in 2007 and subsequently declined. Correspondingly, the number of patients treated with surgery and radiation therapy also reached in a peak in 2007. Of note, however, the number of patients treated with surgery increased relative to

Discussion

Previous studies had demonstrated increasing use of BT relative to EBRT for the treatment of prostate cancer [2], [3], [4], [5], [6], [7]. In the most recent of these studies, for example, Jani et al. (4), using the SEER database, noted that radiation therapy (RT) use steadily increased from 9.1% in 1973 to 26.0% in 2004; and, within RT, EBRT use decreased from 99.3% to 59.3%, whereas BT use increased from 0.0% to 40.7% during the same time period.

Our study, which continues where the study from

Conclusion

In summary, our analysis of this nationwide database reveals evidence of a reversal in the previously increasing utilization of BT for the treatment of prostate cancer. Further followup will be required to determine if this trend persists and for how long. Moreover, further investigation to determine the impact of this trend on health care expenditure is warranted.

References (22)

G.V. Walker et al.
Muddy water? Variation in reporting receipt of breast cancer radiation therapy by population-based tumor registries
Int J Radiat Oncol Biol Phys
(2013)
B.P. Falit et al.
Integrated prostate cancer centers and over-utilization of IMRT: A close look at fee-for-service medicine in radiation oncology
Int J Radiat Oncol Biol Phys
(2010)
J.E. Bekelman et al.
Effect of integration between urologists and radiation oncologists on prostate cancer treatment patterns
J Urol
(2013)
N.G. Zaorsky et al.
Stereotactic body radiation therapy for prostate cancer: Is the technology ready to be the standard of care?
Cancer Treat Rev
(2013)
V. Gondi et al.
Results of the 2005-2008 Association of Residents in Radiation Oncology survey of chief residents in the United States: Clinical training and resident working conditions
Int J Radiat Oncol Biol Phys
(2011)
M.K. Buyyounouski et al.
A survey of current clinical practice in permanent and temporary prostate brachytherapy: 2010 Update
Brachytherapy
(2012)
National Comprehensive Cancer Network. Prostate Cancer V1. 2013. Available at:...
A.S. Hamilton et al.
Trends in the treatment of localized prostate cancer using supplemented cancer registry data
BJU Int
(2011)
B.E. Terakedis et al.
A surveillance, epidemiology, and end results registry analysis of prostate cancer modality time trends by age
Am J Clin Oncol
(2010)
A.B. Jani et al.
Prostate cancer modality time trend analysis from 1973 to 2004: A Surveillance, Epidemiology, and End Results registry analysis
Am J Clin Oncol
(2010)

L.A. Copeland et al.

Impact of brachytherapy on regional, racial, marital status, and age-related patterns of definitive treatment for clinically localized prostate carcinoma

Cancer

(2005)

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Challenges in the Sustainability of Brachytherapy Service in Contemporary Radiotherapy
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Brachytherapy has a long history of delivering a highly conformal radiation dose to the target volume with sparing of adjacent normal tissue and has an irreplaceable role in certain cancers, such as cervical and prostate cancers. There have been futile attempts to replace brachytherapy with other radiation techniques. Despite that there are multifaceted challenges in preserving this dying art, from establishment, to a trained workforce, to maintenance of the equipment and source replacement costs. Here we focus on the challenges to access brachytherapy, the availability and distribution of care across the globe and appropriate training leading to proper implementation of the procedure. Brachytherapy holds a significant place in the treatment armamentarium of most common cancers, such as cervical, prostate, head and neck and skin cancers. However, there is an uneven distribution of brachytherapy facilities, not only across the globe, but also at a national level, with a larger proportion of facilities concentrated in certain regions, more so in low and low-middle income countries. The regions with the highest incidence of cervical cancer have the least access to brachytherapy facilities. Attempts to bridge the gap are essential and should be focused on uniform distribution and access to care, improving training of the workforce through specialised training programmes, reducing the cost of care, planning to reduce the recurring cost, generating evidence and research guidelines, renewing interest in brachytherapy through rebranding, use of social media and building an attainable long-term roadmap.
Real-world utilisation of brachytherapy boost and patient-reported functional outcomes in men who had external beam radiation therapy for prostate cancer in Australia
2022, Clinical and Translational Radiation Oncology
We aimed to evaluate utilisation of brachytherapy (BT) boost in men who had external beam radiation therapy (EBRT) for prostate cancer, and to compare patient-reported functional outcomes (PRO) following each approach in a population-based setting in Australia.
This is a population-based cohort of men with localised prostate cancer enrolled in the Victorian Prostate Cancer Outcomes Registry, who had EBRT between 2015 and 2020. Primary outcomes were proportion who had BT-boost, and PRO (assessed using the EPIC-26 questionnaires) 12 months post-treatment. Multivariable logistic regressions were used to evaluate factors associated with BT-boost, and linear regressions were used to estimate differences in EPIC-26 domain scores between EBRT alone and EBRT + BT.
Of the 1,626 men in the study, 88 (5.4 %) had BT-boost. Factors independently associated with BT-boost were younger age, higher socioeconomic status, and treatment in public institutions. 1,555 men completed EPIC-26 questionnaires. No statistically or clinically significant differences in EPIC-26 urinary, sexual and bowel functional domain scores were observed between men who had EBRT + BT vs EBRT alone, with adjusted mean differences in urinary incontinence, urinary irritative/ obstruction, sexual, and bowel domain of 1.28 (95 %CI = −3.23 to 5.79), −2.87 (95 %CI = −6.46 to 0.73), 0.49 (95 %CI = −4.78 to 5.76), and 2.89 (95 %CI = −0.83 to 6.61) respectively.
1-in-20 men who had EBRT for prostate cancer had BT-boost. This is the first time that PRO following EBRT+/-BT is reported at a population-based level in Australia, with no evidence to suggest worse PRO with addition of BT-boost 12 months post-treatment.
Patient reported outcomes for quality of life (QOL) by Expanded Prostate Cancer Index (EPIC) on average 15 years post treatment
2022, Clinical and Translational Radiation Oncology
Previously patient reported quality of life (QOL) was reported in men with prostate cancer a mean 2 and 6 years post treatment with open radical prostatectomy (RP), 3D conformal radiation therapy (3D CRT), or ¹²⁵I low dose rate (LDR) brachytherapy (BT). Herein we update the results 15 years post-treatment QOL.
The Expanded Prostate Cancer Index (EPIC) domains were scored with differences evaluated at a median 15.8 years follow up based upon mean EPIC summary domains by ANOVA with pairwise post-hoc comparisons adjusted for age. Patient differences of current survey from first cross-section are reported as median change in summary score for each treatment group at median of 2.2 and 6.0, and 15.8 years.
Among men still alive response rate was 52% in BT, 60% in 3D CRT, and 62% in RP resulting in 30, 41, and 330 QOL questionnaires to evaluate for each corresponding modality at median follow up of 15.8 years. Men were a mean 75.3, 83.6, and 79.3 years of age after RP, 3DCRT, and BT, respectively.
At a median of 15.8 years, there were largely persistent differences in EPIC domains without substantial evolution in QoL from middle time points. Persistent worsening in urinary irritative and bowel domain with 3DRT or BT compared to RP. Trend towards worse urinary incontinence with RP were noted without statistical differences within radiotherapy options.
As the EPIC patient reported outcomes with the longest follow-up, these data uniquely reveal temporal trends from 2 to 15 years post treatment. However, the treatment modalities of open RP, 3D CRT without image guidance or intensity modulation, and BT without peripheral loading or MRI guidance may not reflect modern techniques.
Ultrahypofractionated Radiotherapy for Localised Prostate Cancer: How Far Can We Go?
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Following adoption of moderately hypofractionated radiotherapy as a standard for localised prostate cancer, ultrahypofractioned radiotherapy delivered in five to seven fractions is rapidly being embraced by clinical practice and international guidelines. However, the question remains: how low can we go? Can radiotherapy for prostate cancer be delivered in fewer than five fractions? The current review summarises the evidence that radiotherapy for localised prostate cancer can be safely and effectively delivered in fewer than five fractions using high dose rate brachytherapy or stereotactic body radiotherapy. We also discuss important lessons learned from the single-fraction high dose rate brachytherapy experience.
PSA: Declining utilization of prostate brachytherapy
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Citation Excerpt :
Patients were included if they met the following criteria: 18 years of age or older, diagnosed with locoregionally confined adenocarcinoma of the prostate (ICD morphology code 8140) between the years of 2010 and 2015. We included locoregionally confined disease to mirror the paper by Mahmood et al. in order to make a meaningful comparison between their study cohort and our own, providing a longitudinal evaluation of brachytherapy trends over time [12]. We chose to start our data collection from 2010 to provide an update from the previously reported data by Mahmood et al., which looked at brachytherapy trends from 2004 to 2009.
To analyze rates of brachytherapy use for prostate cancer over time and evaluate patient characteristics, demographics and factors predictive for its utilization.
Data was retrospectively analyzed from the National Cancer Database (NCDB) for patients with localized prostate cancer treated between 2010 and 2015. Patients were included if they had biopsy confirmed localized adenocarcinoma of the prostate, were treated with radiation as definitive local therapy, and were at least 18 years old. Utilization rates of external beam radiation (EBRT), brachytherapy (BT) and combination (EBRT + BT) were evaluated over time. Univariable (UVA) and backwards elimination multivariable (MVA) analysis were performed to determine characteristics predictive for brachytherapy use.
We analyzed 178,837 patients with localized adenocarcinoma of the prostate treated between 2010 and 2015 with radiation therapy. During this period, the use of EBRT increased from 67% to 78%, BT (both monotherapy and combination with EBRT) decreased from 33% to 22%, BT monotherapy decreased from 25% to 16% and EBRT + BT decreased from 8% to 6%. Age >70, government funded insurance or lack of insurance, intermediate or high-risk disease and treatment at an academic center were associated with significantly lower utilization of brachytherapy (all p <0.001), while higher median zip code income was associated with increased use (p = 0.02). On multivariable analysis patients who were younger, had private insurance, were lower NCCN risk category and treated in non-academic cancer centers, had a higher rate of brachytherapy utilization. Notably, on both UVA and MVA brachytherapy practice decreased with increasing year of diagnosis (OR 0.881, 95% CI 0.853–0.910, p <0.001).
Rates of brachytherapy utilization for the treatment of prostate cancer continue to decrease over time. Treatment at an academic center was associated with reduced likelihood of brachytherapy use. This has significant implications for the training of future radiation oncology residents/fellows and direct consequences for both our patients and healthcare expenditure.
Trends and variations in utilization and costs of radiotherapy for prostate cancer: A SEER medicare analysis from 2007 through 2016
2022, Brachytherapy
To assess recent changes and disparities in utilization and costs of radiotherapy in Medicare beneficiaries with prostate cancer.
Surveillance, Epidemiology and End Results (SEER) –Medicare linked data from 2006-2016 were used to identify continuously enrolled Medicare beneficiaries with a first-time diagnosis of prostate cancer who, within 12 months of diagnosis, underwent at least one radiotherapy related service. Trends in the utilization of different radiotherapy techniques over time, yearly changes in per-patient costs of radiotherapy, and effect of socio-demographic and clinical characteristics on total cost were measured. Per patient annual costs, annual incidence of prostate cancer, and utilization of radiotherapy were used to estimate total costs of radiotherapy to the Medicare program.
For Medicare beneficiaries with a first-time diagnosis of prostate cancer, the utilization of intensity modulated radiation therapy (IMRT), proton therapy, and stereotactic body radiation therapy (SBRT) increased 23.62%, 0.74% and 1.61% respectively (p <0.0001) while brachytherapy decreased 17.04% (p <0.0001). Cost per beneficiary decreased $340.24 (95% CI: $136.05 - $544.43) annually (p = 0.0065). Age, registry region, and Gleason score were all associated with expenditures. The total cost to the Medicare program was estimated at US $1.16 billion in the year 2016.
In Medicare beneficiaries with prostate cancer treated with radiotherapy, IMRT is the primary mode of treatment. Utilization of brachytherapy decreased significantly despite the efficacy and cost-effectiveness. Although per patient costs have decreased, the share of patient responsibility remained unaltered across years. The current costs to Medicare of radiotherapy for newly diagnosed prostate cancer patients is substantial.

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: Financial disclosures: SF serves as the director of C4 Imaging, Houston, TX.

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Declining use of brachytherapy for the treatment of prostate cancer

Abstract

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Methods and materials

Results

Discussion

Conclusion

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

J Urol

Cancer Treat Rev

Int J Radiat Oncol Biol Phys

Brachytherapy

Trends in the treatment of localized prostate cancer using supplemented cancer registry data

BJU Int

A surveillance, epidemiology, and end results registry analysis of prostate cancer modality time trends by age

Am J Clin Oncol

Prostate cancer modality time trend analysis from 1973 to 2004: A Surveillance, Epidemiology, and End Results registry analysis

Am J Clin Oncol

Impact of brachytherapy on regional, racial, marital status, and age-related patterns of definitive treatment for clinically localized prostate carcinoma

Cancer