Department of Urology, Yale School of Medicine, New Haven, Connecticut.
Frank H. Netter MD School of Medicine at Quinnipiac University, New Haven, Connecticut.
Urol Pract. 2022 Mar;9(2):140-149. doi: 10.1097/UPJ.0000000000000290. Epub 2021 Dec 29.
We sought to understand patient- and institution-level factors associated with use of locoregional therapy for newly diagnosed metastatic prostate cancer in the era before the availability of evidence supporting its efficacy.
We queried the National Cancer Database to identify patients diagnosed with metastatic prostate adenocarcinoma (stage M1) between 2004 and 2017. We assessed patient factors associated with definitive local therapy with radiotherapy or radical prostatectomy using multilevel logistic regression accounting for clustering within institutions. We further characterized trends in facility-level use and examined institutional factors associated with utilization.
We identified 35,933 patients with M1 prostate cancer at 1,188 facilities. A total of 4,146 patients (11.5%) received local therapy for M1 disease (radiation therapy in 3,378 and radical prostatectomy in 768). Use of local treatment was concentrated among a smaller number of facilities: 50% of all local therapy was delivered at 161 facilities (14% of total). At the patient level, uninsured status (OR 0.62, 95% CI 0.49-0.79, p <0.01) and high comorbidity (Charlson-Deyo score, OR 0.39, 95% CI 0.26-0.6, p <0.01) were associated with lower odds of local therapy. High-utilizing facilities (top quartile) were more commonly community centers (OR 1.76, 95% CI 10.7-2.95, p <0.01) and differed by geographic region (South Atlantic vs West South Central region: OR 0.48, 95% CI 0.25-0.88, p=0.02).
In the period before locoregional therapy was supported by clinical practice guidelines, locoregional therapy use varied significantly at the facility level and was driven by a smaller number of high-utilizing facilities. These findings can contextualize expected increase in the use of local therapy for metastatic prostate cancer.
我们试图了解在支持局部区域治疗转移性前列腺癌疗效的证据出现之前，与新诊断的转移性前列腺癌患者和医疗机构使用局部区域治疗相关的因素。
我们查询国家癌症数据库，以确定 2004 年至 2017 年间诊断为转移性前列腺腺癌（M1 期）的患者。我们使用多水平逻辑回归评估与接受放射治疗或根治性前列腺切除术的确定性局部治疗相关的患者因素，同时考虑到医疗机构内的聚类情况。我们进一步描述了医疗机构层面使用的趋势，并检查了与使用相关的医疗机构因素。
我们在 1188 家医疗机构中发现了 35933 名 M1 前列腺癌患者。共有 4146 名患者（11.5%）接受了 M1 疾病的局部治疗（3378 名接受放射治疗，768 名接受根治性前列腺切除术）。局部治疗主要集中在少数医疗机构：50%的局部治疗都在 161 家医疗机构中进行（占总数的 14%）。在患者层面，未参保状态（比值比 0.62，95%置信区间 0.49-0.79，p<0.01）和高合并症（Charlson-Deyo 评分，比值比 0.39，95%置信区间 0.26-0.6，p<0.01）与接受局部治疗的可能性较低相关。高利用率的医疗机构（前四分之一）更常见的是社区中心（比值比 1.76，95%置信区间 10.7-2.95，p<0.01），并且因地理位置不同而有所差异（南大西洋与西南中部地区：比值比 0.48，95%置信区间 0.25-0.88，p=0.02）。
在局部区域治疗得到临床实践指南支持之前，局部区域治疗的使用在医疗机构层面上存在显著差异，且由少数高利用率的医疗机构驱动。这些发现可以为转移性前列腺癌局部治疗使用的预期增加提供背景。
