Overall, though, researchers found that newer, less invasive technologies, like laparoscopic prostate removal, have supplanted older treatment methods like open surgery over time.

“There are several treatment options for men with localized prostate cancer,” said lead author Dr. K. Clinton Cary of the urology department at Indiana University School of Medicine in Indianapolis.

“These options have grown over time to incorporate technology advances,” Cary told Reuters Health by email. Nonetheless, he said, “It is interesting to see how treatment of the same condition varies depending on your geographic location.”

The researchers used data on more than 77,000 men in a Medicare database who were diagnosed with prostate cancer between 1998 and 2006 in addition to more than 63,000 in a private claims database between 2002 and 2006.

Radical prostatectomy, surgery to remove the prostate gland and some surrounding tissue, held steady at 12 percent of patients over time in the Medicare group, but increased from 33 to 48 percent by 2006 in the privately insured group.

This was the most common first method of treatment in the private insurance group in 2002, followed by external beam radiation therapy. In the Medicare group, radiation therapy was the most common first treatment, followed by hormone therapy.

Nine percent of privately insured men and 14 percent of those on Medicare did not immediately receive treatment and were instead assigned “active surveillance,” also known as watchful waiting, an increasingly common approach to early prostate cancers.

Patients in the private insurer group tended to be younger than those on Medicare, and younger patients are more suited to radical prostatectomy, according to Dr. Axel Heidenreich, director of the urology clinic at University Hospital Aachen in Germany, who was not involved in the new study.

“The significant age difference, however, raises the question if (privately insured) patients have better access to the healthcare system in terms of early detection of prostate cancer as compared to the Medicare patients,” Heidenreich told Reuters Health by email.

In 2002, only a fraction of patients in either group underwent laparoscopic-assisted prostate surgery, a robotic version of the surgery that uses smaller incisions and a thin camera to minimize the invasiveness of the procedure.

By 2006, 41 percent of the surgeries in the private insurance group and 35 percent of the surgeries in the Medicare group were laparoscopic, according to the results published in Prostate Cancer and Prostatic Disease.

As robot-assisted prostate surgery became more common in both groups, hormone therapy became less common over time.

In New England, counties with more urologists per capita had lower rates of radical prostatectomy and hormone therapy, and areas with more radiation oncologists had higher rates of radiation therapy. This physician-density pattern was not seen in California or Florida, however.

In each state, Cary noted, there was considerable variation in treatments even between counties. “These counties could be bordering one another and yet the proportion receiving radiation could be between 20 to 50 percent higher in one of the counties compared to the other,” he said.

Although insurance reimbursement was not included in the study, it may unfortunately explain some of the local and regional variation, he said. Presumably, treatments with higher reimbursements would be more common.

“Different treatments would certainly have the possibility to yield various outcomes,” Cary said, although the study did not include that information. Because they didn’t have information about the men’s tumor characteristics, the study team can’t say whether the changes over time or by region are necessarily for the better or worse.

“Variations do exist, but this doesn’t necessarily equate to inappropriate care,” he said.

“Patients should largely rely on their treating physicians for treatment advice,” Cary said. “Patients may consider seeking second opinions from high-volume centers which may include their local academic medical centers that have experience with all treatment options and can report their own tracked outcomes.”

SOURCE: bit.ly/1B7yTVO Prostate Cancer and Prostatic Disease, online February 10, 2015.


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