Friedlander David F, von Landenberg Nicolas, Löppenberg Björn, Noldus Joachim, Lipsitz Stuart R, Cole Alexander P, Abdollah Firas, Nguyen Paul L, Choueiri Toni K, Kibel Adam S, Trinh Quoc-Dien
Division of Urological Surgery, Harvard Medical School , Boston , Massachusetts.
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School , Boston , Massachusetts.
J Urol. 2019 Apr;201(4):728-734. doi: 10.1097/JU.0000000000000006.
We sought to identify facility level variation in the use of definitive therapy among men diagnosed with clinically localized, low risk prostate cancer who were more than 65 years old and had a limited life expectancy of less than 10 years.
Using data from the National Cancer Database we identified 18,178 men older than 65 years with less than a 10-year life expectancy receiving definitive therapy at a total of 1,172 facilities for biopsy confirmed localized, low risk prostate cancer diagnosed between January 2004 and December 2013. A multilevel, hierarchical, mixed effects logistic regression model was fitted to predict the odds of receiving definitive therapy.
Overall 18,178 men (76%) older than 65 years with limited life expectancy and a diagnosis of low risk prostate cancer received definitive therapy, although the rate of therapy decreased significantly with time (p <0.001). Patients receiving definitive therapy were more often younger (80 years or older vs 66 to 69 years OR 0.12, 95% CI 0.09-0.15, p <0.001) and white rather than black (OR 0.86, 95% CI 0.75-0.98, p = 0.03). Conversely, being uninsured (OR 0.37, 95% CI 0.21-0.63, p <0.001) and receiving care at an academic medical center (OR 0.36, 95% CI 0.28-0.46, p <0.001) conferred decreased odds of undergoing definitive therapy. The proportion of men undergoing definitive therapy ranged from 0.12% to 100% across facilities.
We found significant facility level variation in rates of definitive therapy in men with localized prostate cancer and limited life expectancy. Health care providers and policy makers alike should be aware of the varying frequency with which this potentially low value service is performed.
我们试图确定在年龄超过65岁、预期寿命不足10年且被诊断为临床局限性、低风险前列腺癌的男性中，确定性治疗使用情况在机构层面的差异。
利用国家癌症数据库的数据，我们确定了18178名年龄超过65岁、预期寿命不足10年的男性，他们在2004年1月至2013年12月期间于1172家机构接受了活检确诊的局限性、低风险前列腺癌的确定性治疗。采用多水平、分层、混合效应逻辑回归模型来预测接受确定性治疗的几率。
总体而言，18178名年龄超过65岁、预期寿命有限且被诊断为低风险前列腺癌的男性接受了确定性治疗（76%），尽管治疗率随时间显著下降（p<0.001）。接受确定性治疗的患者更常为较年轻者（80岁及以上与66至69岁相比，比值比0.12，95%置信区间0.09 - 0.15，p<0.001）且为白人而非黑人（比值比0.86，95%置信区间0.75 - 0.98，p = 0.03）。相反，未参保（比值比0.37，95%置信区间0.21 - 0.63，p<0.001）以及在学术医疗中心接受治疗（比值比0.36，95%置信区间0.28 - 0.46，p<0.001）会使接受确定性治疗的几率降低。各机构中接受确定性治疗的男性比例从0.12%到100%不等。
我们发现，在局限性前列腺癌且预期寿命有限的男性中，确定性治疗率在机构层面存在显著差异。医疗保健提供者和政策制定者都应意识到这种潜在低价值服务的执行频率各不相同。
