University of California, San Francisco, Box 1695, 1600 Divisadero St, A-607, San Francisco, CA 94143-1695, USA.
J Clin Oncol. 2010 Mar 1;28(7):1117-23. doi: 10.1200/JCO.2009.26.0133. Epub 2010 Feb 1.
PURPOSE In the absence of high-level evidence or clinical guidelines supporting any given active treatment approach over another for localized prostate cancer, clinician and patient preferences may lead to substantial variation in treatment use. METHODS Data were analyzed from 36 clinical sites that contributed data to the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry. Distribution of primary treatment use was measured over time. Prostate cancer risk was assessed using the D'Amico risk groups and the Cancer of the Prostate Risk Assessment (CAPRA) score. Descriptive analyses were performed, and a hierarchical model was constructed that controlled for year of diagnosis, cancer risk variables, and other patient factors to estimate the proportion of variation in primary treatment selection explicable by practice site. Results Among 11,892 men analyzed, 6.8% elected surveillance, 49.9% prostatectomy, 11.6% external-beam radiation, 13.3% brachytherapy, 4.0% cryoablation, and 14.4% androgen deprivation monotherapy. Prostate cancer risk drives treatment selection, but the data suggest both overtreatment of low-risk disease and undertreatment of high-risk disease. The former trend appears to be improving over time, while the latter is worsening. Treatment varies with age, comorbidity, and socioeconomic status. However, treatment patterns vary markedly across clinical sites, and this variation is not explained by case-mix variability or known patient factors. Practice site explains a proportion of this variation ranging from 13% for androgen deprivation monotherapy to 74% for cryoablation. CONCLUSION Substantial variation exists in management of localized prostate cancer that is not explained by measurable factors. A critical need exists for high-quality comparative effectiveness research in localized prostate cancer to help guide treatment decision making.
在缺乏高级别证据或临床指南支持任何特定的局部前列腺癌治疗方法优于另一种方法的情况下，临床医生和患者的偏好可能导致治疗方法的大量差异。
分析了来自参与癌症前列腺战略泌尿外科研究努力（CaPSURE）登记处的 36 个临床站点的数据。随着时间的推移，测量了主要治疗方法的分布。使用 D'Amico 风险组和前列腺癌风险评估（CAPRA）评分评估前列腺癌风险。进行了描述性分析，并构建了一个分层模型，该模型控制了诊断年份、癌症风险变量和其他患者因素，以估计由实践站点解释的主要治疗选择变化的比例。
在分析的 11892 名男性中，6.8%选择了监测，49.9%选择了前列腺切除术，11.6%选择了外照射放疗，13.3%选择了近距离放疗，4.0%选择了冷冻消融，14.4%选择了雄激素剥夺单药治疗。前列腺癌风险决定了治疗选择，但数据表明，低危疾病存在过度治疗，高危疾病存在治疗不足。前者的趋势似乎随着时间的推移而改善，而后者则在恶化。治疗方法随年龄、合并症和社会经济地位而变化。然而，治疗模式在临床站点之间存在显著差异，这种差异不能用病例组合的可变性或已知的患者因素来解释。实践站点解释了这种变化的一部分，从雄激素剥夺单药治疗的 13%到冷冻消融的 74%。
局部前列腺癌的管理存在大量差异，这些差异无法用可衡量的因素来解释。迫切需要在局部前列腺癌中开展高质量的比较效果研究，以帮助指导治疗决策。
