Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany.
Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Urol Oncol. 2019 Sep;37(9):575.e9-575.e18. doi: 10.1016/j.urolonc.2019.04.001. Epub 2019 May 2.
A considerable number of prostate cancer (PCa) patients eligible for expectant management receive definitive treatment. We aimed to investigate the hospital-level contribution to overtreatment in the United States.
Using the National Cancer Database we identified two nonoverlapping cohorts: (1) men with a life expectancy <10 years harbouring low or intermediate risk PCa (2) men with life expectancy ≥10 years with low-risk PCa. Multivariable mixed models with patient characteristics as fixed and hospital-level intercept as random effect were used to assess the hospital-level risk-adjusted probability of definitive treatment in both groups. Pearson's correlation coefficient was calculated to investigate the correlation between the hospitals probabilities of treating patients of both cohorts.
We found 33,431 men with a life expectancy <10 years and 122,514 men with a life expectancy ≥10 years and low-risk PCa. In the latter, the probability of treatment ranged from 29.0% in the bottom to 90.0% in the top decile and from 35.0% to 88.0% for men with a life expectancy <10 years. Age and race were independent predictors of low-value treatment in both cohorts. The correlation between 1,225 hospitals treating men of both cohorts was strong (Pearson's r = 0.66, P < 0.001).
There is wide hospital-level variability in low-value treatment of men with limited life expectancies and low-risk PCa. Hospitals more likely to treat men with limited life expectancies were more likely to treat men with low-risk PCa and vice versa. Identifying drivers and modifying practice at these hospitals may represent an effective tool for reducing overtreatment.
相当数量适合期待管理的前列腺癌 (PCa) 患者接受了确定性治疗。我们旨在研究美国医院层面治疗过度的原因。
我们使用国家癌症数据库确定了两个不重叠的队列：(1) 预期寿命<10 年且患有低危或中危 PCa 的男性；(2) 预期寿命≥10 年且患有低危 PCa 的男性。使用多变量混合模型，患者特征为固定因素，医院水平截距为随机因素，评估两组中确定性治疗的医院水平风险调整概率。计算 Pearson 相关系数，以研究两个队列患者治疗概率之间的相关性。
我们发现 33431 名预期寿命<10 年的男性和 122514 名预期寿命≥10 年且患有低危 PCa 的男性。在后一组中，治疗概率范围从底部的 29.0%到顶部的 10.0%，而对于预期寿命<10 年的男性，治疗概率范围从 35.0%到 88.0%。年龄和种族是两个队列中低价值治疗的独立预测因素。治疗两个队列男性的 1225 家医院之间的相关性很强（Pearson r=0.66，P<0.001）。
对于预期寿命有限且患有低危 PCa 的男性，医院之间在低价值治疗方面存在广泛的差异。更有可能治疗预期寿命有限的男性的医院也更有可能治疗患有低危 PCa 的男性，反之亦然。确定这些医院的驱动因素并修改实践可能是减少过度治疗的有效工具。
