Department of Internal Medicine, University of Michigan Medical School, Michigan, Ann Arbor, USA.
VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Michigan, Ann Arbor, USA.
Cancer Med. 2023 Mar;12(6):6945-6955. doi: 10.1002/cam4.5490. Epub 2023 Feb 15.
Over the past decade, abiraterone and enzalutamide have largely replaced ketoconazole as oral treatments for castration-resistant prostate cancer (CRPC). We investigated the differential adoption of abiraterone and enzalutamide across facilities in a national healthcare system to understand the impact a facility has on the receipt of these novel therapies.
Using data from the VA Corporate Data Warehouse, we identified a cohort of men with CRPC who received the most common first-line therapies: abiraterone, enzalutamide, docetaxel, or ketoconazole between 2010 and 2017. We described variability in the adoption of abiraterone and enzalutamide across facilities by time period (2010-2013 or 2014-2017). We categorized facilities depending on the timing of adoption of abiraterone and enzalutamide relative to other facilities and described facility characteristics associated with early and late adoption.
We identified 4998 men treated with ketoconazole, docetaxel, abiraterone, or enzalutamide as first-line CRPC therapy between 2010 and 2017 at 125 national facilities. When limiting the cohort to oral therapies, most patients treated earlier in the study period (2010-2013) received ketoconazole. A dramatic shift was seen by the second half of the study period (2014-2017) with most men treated with first-line abiraterone (61%). Despite this shift and a new standard of care, some facilities persisted in the widespread use of ketoconazole in the later period, so-called late adopting facilities. After multivariable adjustment, patients who received treatment at a late adopting facility were more likely receiving care at a lower complexity, rural facility, with less urology and hematology/oncology workforce (all p < 0.01).
Many facilities persisted in their use of ketoconazole as first-line CRPC therapy, even when other facilities had adopted the new standard of care abiraterone and enzalutamide. Further work is needed to identify the effect of this late adoption on outcomes important to patients.
在过去的十年中，阿比特龙和恩杂鲁胺已在很大程度上取代了酮康唑，成为治疗去势抵抗性前列腺癌（CRPC）的口服药物。我们研究了在一个全国性医疗保健系统中，不同医疗机构对阿比特龙和恩杂鲁胺的采用情况，以了解医疗机构对这些新型疗法的接受程度。
我们使用退伍军人事务部企业数据仓库的数据，确定了一组在 2010 年至 2017 年间接受最常见一线治疗的 CRPC 男性患者队列：阿比特龙、恩杂鲁胺、多西他赛或酮康唑。我们描述了不同医疗机构在不同时间段（2010-2013 年或 2014-2017 年）对阿比特龙和恩杂鲁胺的采用情况的差异。我们根据阿比特龙和恩杂鲁胺的采用时间相对于其他医疗机构对医疗机构进行分类，并描述了与早期和晚期采用相关的医疗机构特征。
我们在 125 个国家医疗机构中确定了 4998 名接受酮康唑、多西他赛、阿比特龙或恩杂鲁胺作为一线 CRPC 治疗的患者，他们在 2010 年至 2017 年间接受了治疗。当将队列限制为口服药物治疗时，大多数在研究早期（2010-2013 年）接受治疗的患者接受了酮康唑治疗。在研究的后半期（2014-2017 年）出现了显著变化，大多数患者接受了一线阿比特龙治疗（61%）。尽管发生了这种转变和新的治疗标准，但一些医疗机构在后期仍广泛使用酮康唑，即所谓的晚期采用机构。在多变量调整后，在晚期采用机构接受治疗的患者更有可能在复杂性较低、农村地区的医疗机构接受治疗，并且泌尿外科和血液/肿瘤学劳动力较少（均 p<0.01）。
许多医疗机构仍在将酮康唑作为一线 CRPC 治疗药物，即使其他医疗机构已采用新的治疗标准阿比特龙和恩杂鲁胺。需要进一步研究以确定这种晚期采用对患者重要结局的影响。
