Radical Prostatectomy Rates Research Articles

Impact of fellowship training on pathologic outcomes and complication rates of radical prostatectomy

The study was conducted to assess the results of radical prostatectomy (RP) performed by fellowship-trained surgeons in the first year of independent practice. A prospective cohort study of 66 men who underwent RP performed by 2 recently graduated fellowship-trained surgeons (C.J.R., n = 27; A.M.K., n = 39) in their first year of independent practice was undertaken. Preoperative, operative, and postoperative data were collected and analyzed. Median follow-up of the cohort is 12.5 months. The median patient age was 61.2 +/- 6.9 years (range, 44-74 years), the median prostate-specific antigen level was 5 ng/mL (range, 1.2-39.4 ng/mL), and the median prostate biopsy-determined Gleason score was 7. Of the 66 men, 25 (38%) underwent a bilateral nerve-sparing RP, 20 (30%) underwent a unilateral nerve-sparing RP, and 21 (32%) underwent a nonnerve-sparing procedure. Forty-two men (63%) underwent a pelvic lymph node dissection. The median operative time was 201 minutes. Median estimated blood loss was 734 mL (range, 300-1600 mL). There were 4 major complications--a pulmonary embolism in 3 patients and an intraoperative rectal injury in 1. Pathologic classification was as follows: pT2, 74%; pT3a, 23%; pT3b, 2%; and pN+, 2%. The positive margin rate was 14% overall and only 2% in men with pT2 disease. Results of RP performed by fellowship-trained surgeons in their first year of practice compare favorably with results of RP in a large series reported by more experienced surgeons. Being trained in an environment where an experienced surgeon serves as first assistant to the trainee appears to abbreviate the learning curve associated with this procedure.

Trends in in-patient Hospital Utilization and Surgical Procedures for Breast, Prostate, Lung and Colorectal Cancers in Canada

To analyse population-based trends of in-patient surgical procedures for breast (female), prostate, lung and colorectal cancers. The Hospital Morbidity Files supplied hospital data and the Canadian Cancer Registry, incidence data. Age-adjusted rates were standardized to the 1991 Canadian population. All four cancers showed major changes in trends of surgical procedures. For breast cancer, the rate of in-patient breast conservation surgery (BCS) increased from 1981 to the early 1990s while the rate of mastectomy decreased. Because day surgery was not included, the subsequent in-patient BCS rate stayed level. For prostate cancer, the rate of transurethral prostatectomy was initially high but decreased after 1990, while the rate of radical prostatectomy increased rapidly, only minimally affected by the PSA-related peak in incidence. The lung cancer lobectomy rate in men remained at 10/100,000 after 1986, but in women rose from 3/100,000 to 7/100,000, reflecting increasing lung cancer incidence. For colorectal cancer, right hemicolectomies and anterior resections increased, especially in men. Surgery trends reflected changes in incidence and treatment preferences. Canadian trends were generally similar to US trends, although the timing of some of the changes differed. Canadians tended to use less invasive procedures such as BCS and anterior resection.

Role of Salvage Radical Prostatectomy for Recurrent Prostate Cancer After Radiation Therapy

Patients with isolated local recurrence of prostate cancer after radiation therapy may potentially be cured of their disease by salvage radical prostatectomy (RP). The stage-specific 5-year cancer-control rates of salvage RP resemble those of standard RP. However, the ability to effectively administer salvage treatment to patients with radiorecurrent disease is compromised by the lack of diagnostic tests with sufficient sensitivity and specificity to detect local recurrence at an early stage while it is amenable to local salvage therapy. By the time biochemical recurrence is declared using the current American Society for Therapeutic Radiology and Oncology definition, the majority of patients have advanced local disease, precluding successful local salvage therapy. When salvage RP is performed at prostate-specific antigen levels of 10 ng/mL or less, an estimated 70% of patients are free of disease at 5 years. With better patient selection and technical modifications, the morbidity associated with salvage RP has improved substantially. Rates of urinary incontinence and anastomotic stricture are acceptable, although one third of patients will experience these complications. Salvage cryotherapy is a minimally invasive alternative to salvage RP, but cancer-control rates appear to be inferior and it does not provide a clear advantage over salvage RP in terms of reduced morbidity. Patients with local recurrence after radiation therapy are at increased risk of metastatic progression and cancer-specific mortality. Currently, salvage RP represents the only curative treatment option for these patients. Salvage RP may favorably alter the natural history of biochemical recurrence after radiation therapy, but it must be instituted early in the course of recurrent disease to be effective.

Urban–rural differences in prostate cancer mortality, radical prostatectomy and prostate‐specific antigen testing in Australia

To assess differences in trends for prostate cancer mortality, radical prostatectomy and prostate-specific antigen (PSA) testing for Australian men aged 50-79 years living in capital cities compared with regional and rural areas. Descriptive, population-based study based on data from official sources from 1985 to the 2002/03 financial year (depending on data availability). Age-standardised rates per 100,000 men aged 50-79 years of mortality from prostate cancer, incidence of prostate cancer, PSA tests and radical prostatectomy. We found a statistically significant and increasing (age-standardised) mortality excess for prostate cancer in regional and rural areas. In 2000-2002 the excess (compared with capital cities) was 21% (95% CI, 14%-29%). Rates of radical prostatectomy in rural and regional Australia were 29% lower (95% CI, 23% lower to 35% lower) than in capital cities. Although PSA testing is common across the whole of Australia, age-standardised rates in 2002/03 were 16% lower (95% CI, 15% lower to 17% lower) in regional and rural areas than in capital cities. Our results show that the probability of a man having a PSA test and the management of his prostate cancer depend on where he lives. The cause or causes of the prostate cancer mortality excess in regional/rural areas cannot be established in a descriptive study, but fewer radical prostatectomies in regional and rural areas, perhaps associated with less PSA screening, remain among the several competing hypotheses. Other possibilities are related to other differences in management, perhaps associated with access to urologists. Governments and other budget holders need good evidence about the effectiveness of prostate cancer screening and early treatment, but also about the best strategies for providing equitable access to cancer services in both urban and rural areas.

IS HISPANIC RACE AN IMPORTANT PREDICTOR OF TREATMENT FAILURE FOLLOWING RADICAL PROSTATECTOMY FOR PROSTATE CANCER?

Hispanic-Americans are the fastest growing minority group in the United States. Many studies have compared prostate cancer treatment outcomes between black and white men, but few such studies have been done with Hispanic men. We compared clinical and pathological features as well as the treatment failure rate of radical prostatectomy in contemporaneously treated groups of Hispanic and white men with prostate cancer. Between 1995 and 2002, 136 Hispanic men and 315 white men underwent radical prostatectomy. Treatment failure was defined as having a prostate specific antigen (PSA) of 0.2 or greater more than 8 weeks after surgery or receiving any adjuvant therapy. Known predictors of failure and race were evaluated for their ability to predict treatment failure. Median followup was 32 months for Hispanic and 36 months for white patients. Hispanic men were older, had a higher percentage of abnormal rectal examinations, Gleason 7 tumors and preoperative PSA levels greater than 10. Preoperative PSA, specimen Gleason score, pathological stage and surgical margin were all strongly associated with treatment failure (p<0.001). Despite differences in clinical characteristics, overall failure rates did not differ between Hispanic and white men (18.7% vs 17.8%). The odds ratio for treatment failure for Hispanic relative to white men after adjusting for the previously mentioned risk factors was 0.87 (95% CI [0.44, 1.68], p = 0.670). This study shows that Hispanic race does not influence the treatment failure rate of radical prostatectomy in contemporaneously treated patients with prostate cancer at 1 institution. To our knowledge this study represents the largest of its kind, but longer followup and other confirmatory studies are needed.

Is there age bias in the treatment of localized prostate carcinoma?

Treatment recommendations for localized prostate carcinoma are based on the patient's remaining life expectancy (RLE), which is influenced by age, comorbidity, and tumor grade. Previous studies have evaluated the influence of age and comorbidity, but to the authors' knowledge not RLE, on actual treatment decisions. An age-stratified random sample of 347 patients was generated from a cohort of all patients with newly diagnosed prostate carcinoma in the Ontario Cancer Registry between May 1, 1995 and April 30, 1996 (n = 5192). Chart review was performed to obtain detailed tumor, comorbidity, and treatment information. RLE was estimated from a published model derived from a cohort of 451 men with untreated prostate carcinoma who were followed for 15 years. Multivariable logistic regression was performed to evaluate predictors of treatment, such as radical prostatectomy (RP), radiotherapy (RT), or potentially curative therapy (RP or RT), in relation to patient age, comorbidity, tumor characteristics, and RLE. RP was provided within 6 months of diagnosis to 58.7%, 32.1%, 2.6%, and 0% of patients of ages < 60 years, 60-69 years, 70-79 years, and 80+ years, respectively. The results for RT were 6.4%, 30.9%, 23.4%, and 3.3%, respectively. Increasing comorbidity decreased rates of RP but did not affect use of RT. After controlling for comorbidity and tumor characteristics, older men were found to be treated with RP less often than younger men with similar RLE, whereas RLE did not appear to influence receipt of RT. Although different mechanisms may account for these results, an age bias may be present among urologists and radiation oncologists treating men with localized prostate carcinoma.

Indications for and results of radical prostatectomy

Radical prostatectomy represents the mainstay of therapy for clinically localized prostate cancer. The combination of diagnostic parameters such as PSA or biopsy Gleason grade in nomograms allows a safe prediction of pathologic stage and prognosis of the disease. Imaging techniques are useful in a subset of patients. International studies have proven a high cancer control rate of radical prostatectomy. A nerve-sparing modification of the operative technique does not compromise radicality of the procedure if patients are carefully selected. For this purpose simple and reliable algorithms are available.

Long-term results of three-dimensional conformal adjuvant and salvage radiotherapy after radical prostatectomy

Objectives To evaluate the efficacy and toxicity of three-dimensional conformal radiotherapy (3D-CRT) in the adjuvant and salvage setting after radical prostatectomy (RP). Methods From 1986 to 1997, 38 patients received adjuvant 3D-CRT, with a median time from RP to 3D-CRT of 2.8 months, and 57 patients were treated with salvage RT for a rising prostate-specific antigen with a median time to 3D-CRT of 27.7 months. The median radiation dose was 64.8 Gy. The median follow-up from completion of RT was 7.0 years (range 1.0 to 14.2). Results Overall, the 8-year actuarial rate of biochemical disease-free survival was 40% in all patients. The 8-year biochemical disease-free survival rate was 45% (standard error [SE] 8%) and 30% (SE 7%) for the adjuvant and salvage group, respectively, from RT completion. When measured from the date of RP, the 5 and 8-year biochemical disease-free survival rate for salvage radiotherapy was 58% and 37%, respectively. The corresponding results for adjuvant RT were similar at 53% and 45%. On multivariate analysis, the Gleason score was the only prognostic factor predictive of prostate-specific antigen failure in the salvage group. No prognostic factor was significant in the adjuvant group. The prevalence of major complications after 3D-CRT was low using physician-reported data. Conclusions Long-term biochemical control can be achieved in both adjuvant and salvage settings. For patients receiving salvage RT, a Gleason score greater than 7 was predictive of prostate-specific antigen failure. Prospective trials are needed to improve further on these results.

Rise and fall of radical prostatectomy rates from 1989 to 1996

Objectives. To describe the changes in the rates of radical prostatectomy procedures, prostate-specific antigen (PSA) screening tests among Medicare beneficiaries, and the incidence of prostate cancer in the United States and to explain the exaggerated increase and decrease in the frequency of radical prostatectomy from 1989 to 1996.Methods. Medicare claims data on radical prostatectomy procedures and screening PSA tests and the National Cancer Institute’s Surveillance, Epidemiology, and End Results prostate cancer incidence data were used to estimate the rates of PSA testing and radical prostatectomy among Medicare beneficiaries aged 65 to 74 years and 75 years and older (population rates). The age-specific true rates of the procedure were also estimated for the incident cases of prostate cancer (the population at risk of undergoing radical prostatectomy) among the beneficiaries.Results. The PSA test, prostate cancer incidence, and radical prostatectomy rates increased from 1989 to 1992. Thereafter, the incidence of prostate cancer, and the population and true rates of radical prostatectomy declined. The percentage of increase and decrease in the population rate of radical prostatectomy was approximately twice that in its true rate.Conclusions. The radical prostatectomy rates based on all Medicare beneficiaries grossly exaggerated the changes in the use of the procedure. Where possible, true rates, using the population at risk as the denominator, should be used in the studies of diagnostic and therapeutic procedures, complications, and adverse effects.

Treatments for prostate cancer in older men: 1984–1997

Objectives. To examine the temporal trends in radical prostatectomy (RP), brachytherapy (BT), and external beam radiotherapy (EBRT) rates among men aged 65 years or older for the period 1984 to 1997. Methods. We used the retrospective population-based analysis of treatments for prostate cancer among Medicare beneficiaries. The rates of RP were obtained from Part A (hospital) Medicare data for 20% of the national sample for 1984 to 1997. The BT and EBRT rates for the period 1993 to 1997 were obtained from a 5% national sample of Physician/Supplier Part B data. The rates of treatment, 30-day mortality, and readmissions were included. Results. The rate of RP peaked in 1992. From 1993 to 1997, its use decreased by 6% among men aged 65 to 69 years, 34% among men aged 70 to 74 years, and 50% for men aged 75 years or older. However, by 1997, the RP + BT treatment rate again approached the 1992 levels of RP alone; BT was used twice as often as RP in men aged 75 years or older. By 1997, the RP + BT + EBRT rate exceeded the 1993 rate for men aged 65 to 69 years and was again approaching the 1993 rate for men aged 70 to 74 years. From 1984 to 1997, the presence of comorbid conditions gradually declined for RP and accounted for more than 60% of the decrease in the short term mortality during this period. Variations in RP use by geographic region have also decreased. Conclusions. RP is now more selectively targeted for treatment of prostate cancer in men older than 70 years than in the past. However, since BT has been substituted for radical surgery in many of these older men, the total population-based treatment rates have changed very little over time.

Ultrasound guided transperineal implant (IMP) versus radical prostatectomy (RP) for early prostate cancer

Purpose: At our institution, both IMP therapy and RP are considered appropriate therapies for early clinical stage T1c and T2 prostate cancer based on both physician and patient preferences. This study was undertaken to compare the biochemical disease free (bNED) survival rates of IMP therapy versus RP performed at a single institution.

Trend and Variation in Treatment of Localized Prostate Cancer in the Southern Part ofThe Netherlands, 1988–1996

Objective: To investigate whether the large increase in the incidence of early prostate cancer has led to subsequent increased application of curative treatment and whether similar patterns of treatment were observed in the various hospitals in the area of this investigation. Methods: Using the Eindhoven Cancer Registry, all patients newly diagnosed with prostate cancer between 1988 and 1996 in the southern part of The Netherlands were included in the study. Initial treatment was analyzed for 4,073 patients, of whom the proportion with clinically localized prostate cancer (T1–T3, M0–Mx) increased from 52% in 1988–1990 to 74% in 1994–1996. Results: The proportion of patients with localized prostate cancer treated with radical prostatectomy increased from 11 to 34% among patients under age 70. Especially in 1994–1996, a group of smaller hospitals (n = 11) with a rather low proportion of patients treated by radical prostatectomy (5–52%) could be distinguished from a group of larger hospitals (n = 5) with a large proportion of patients treated by radical prostatectomy (35–67%). Radiotherapy was a more frequent option in hospitals with low radical prostatectomy rates. The proportion of patients aged 70–74 years undergoing radiotherapy increased from 31 to 41%. Over 80% of the patients aged 75 years or older were treated conservatively during the whole study period. Conclusion: Increased detection of localized prostate cancer resulted in increased application of curative treatment for patients under 70 years of age, but a substantial variation was observed between hospitals in the application of radical prostatectomy and radiotherapy.

HAVE COMPLICATION RATES DECREASED AFTER TREATMENT FOR LOCALIZED PROSTATE CANCER?

Purpose The American Urological Association Prostate Cancer Clinical Guidelines Panel reviewed 12,501 publications on prostate cancer from 1955 to 1992 to determine whether the complication rates of external beam radiation therapy, interstitial radiotherapy and radical prostatectomy have decreased. Materials and Methods Complications reported in at least 6 series, study duration and sample sizes were extracted. Year specific study weighted mean patient ages and complication rates were computed. Regression analysis was performed of the study year on weighted mean patient age and complication rate. Results Study year had a significant effect on mean patient age and rate of the majority of complications examined. Data indicated a gradual increase in study patient age and a simultaneous decrease in complications from 1960 to 1990. Conclusions Complication rates in the treatment of localized prostate cancer have decreased during the last 20 to 40 years. This decrease occurred despite evidence that the average age of treated patients had increased during the same period.

SECULAR CHANGES IN RADICAL PROSTATECTOMY UTILIZATION RATES IN OLMSTED COUNTY, MINNESOTA 1980 TO 1995

Purpose We estimated the changes in utilization of radical prostatectomy for treatment of prostate cancer and describe the clinical characteristics of men undergoing radical prostatectomy in a population based setting. Materials and Methods The Rochester Epidemiology Project was used to identify all Olmsted County residents who underwent radical prostatectomy from 1980 to 1995. The community medical records of these men were reviewed to determine the clinical and pathological stage and grade at biopsy and following surgery. Results From 1980 to 1995, 311 radical prostatectomies were performed on Olmsted County men. From 1980 to 1987 prostatectomy rates ranged from 6.3 to 31.0/100,000 men but rates increased dramatically to 53.6/100,000 in 1988 and 106.2/100,000 in 1992. The rate after 1992 decreased to 53.0/100,000 and then increased slightly to 80.4/100,000. There was a shift to younger age in more recent times (mean patient age 65.4 years in 1980 to 1986 and 62.4 in 1993 to 1995, p = 0.02), a nonsignificant (p = 0.10) trend toward lower pathological stage in recent years (42% stage pT2 in 1980 to 1986 versus 55% in 1993 to 1995) and a significant decrease in the proportion of cases of disease up staged following surgery (53% in 1980 to 1986 versus 37% in 1993 to 1995, p = 0.03). There was no significant trend in pathological grade with time (63% Mayo grade I or II in 1980 to 1986 versus 52% in 1993 to 1995, p = 0.30). Conclusions These findings demonstrate an increase in radical prostatectomy rates that coincided with increases in prostate cancer incidence. There was a decrease in population prostatectomy rates in 1993 which was followed by modest increases to levels lower than the peak in 1992. However, the clinical characteristics of patients during this period did not change dramatically, suggesting that in a population based setting the selection factors for patients undergoing surgical treatment may not have changed.

Population-based prostate cancer trends in the United States: patterns of change in the era of prostate-specific antigen

We reviewed prostate cancer trends prior to and during the prostate-specific antigen (PSA) era using data reported from population-based tumor registries in the United States. On the basis of a summary of reports from several population-based tumor registries, prostate cancer incidence rose abruptly during the PSA era, peaked in 1992, and then fell just as abruptly. Prostate cancer incidence in the United States now appears to be approaching levels seen in the pre-PSA era. The flux in prostate cancer incidence (in both magnitude and slope) during the years 1988-1995 is without precedent in oncology. As expected, an age and stage migration toward early age and early stage has been observed. Unexpectedly, grade has shifted heavily toward moderate differentiation, whereas rates of poorly and well-differentiated disease have remained relatively stable. Local treatment rates, particularly radical prostatectomy rates, have risen substantially. Mortality rates appear to have leveled or declined slightly since 1991 after years of steady rise.

Use of Radical Prostatectomy Among Medicare Beneficiaries Before and After the Introduction of Prostate Specific Antigen Testing

Purpose We monitored the use of radical prostatectomy in medicare beneficiaries before and after the introduction of prostate specific antigen (PSA) testing. Materials and Methods Radical prostatectomies performed on medicare beneficiaries between 1984 and 1995 were identified through the medicare claims data base. Medicare enrollment files were used to define the population at risk and age-adjusted rates were standardized to the 1990 United States medicare population. Results Rates of radical prostatectomy have steadily increased since 1984. A sharp increase in radical prostatectomy rates followed the institution of PSA testing after which a prominent decrease, particularly among older age groups, was evident. During the peak year of 1992 the age-adjusted rates of radical prostatectomy for white and black men 65 to 79 years old in the United States were 461.2 and 294.5/100,000 men. Between 1992 and 1995 the rates of radical prostatectomy among white men decreased by 22, 47 and 69% for patients 65 to 69, 70 to 74 and 75 to 79 years old, respectively. The corresponding changes among black men were +6, -18 and -47%, respectively. Differences in the age-adjusted rates between white and black men have narrowed in recent years, ranging from 166.7 (1992) to 29.7 (1995)/100,000 men. Conclusions Recent years have been marked by a rapid increase in the use of radical prostatectomy, which peaked in 1992. Subsequent to 1992 a sharp decrease occurred, which was particularly evident in older and white men. Racial differences in the use of radical prostatectomy have narrowed in recent years.

Trends in radical prostatectomy in New York State.

The purpose of this study was to examine trends in radical prostatectomy in New York State for the period 1991-1993. A retrospective analysis was conducted of all radical prostatectomies performed on hospitalized male Medicare beneficiaries in New York State for the period 1991-1993. Basic trend data were also analyzed for 1990. Pattern analysis was conducted on the 4,154 procedures performed between 1990-1993. In depth hospital chart review was conducted of the 220 cases of radical prostatectomy performed in patients 75 years of age and over between 1991 and 1993 and of a random sample of 263 of 1,266 patients 70-74 years of age. A total of 452 hospital charts were examined for a broad range of information, including family history and therapeutic preferences, preoperative work-up, staging, intraoperative and postoperative transfusions, postoperative complications, and mortality. The rate of radical prostatectomy dramatically rose among New York State male Medicare beneficiaries between 1990 and 1992 and remained at a high plateau in 1993. Pattern analysis revealed a tripling of the procedure rate among those 70-74 years of age and a doubling of the rate in those 75 years of age and older. It was also found that a high proportion of radical prostatectomies in men 70 years of age and older were performed by relatively few hospitals. Although rates of radical prostatectomy rose in New York State during the period under study, these rates were lower than those reported several years earlier in other parts of the country. This may reflect an overall conservative approach to the management of prostate cancer, especially among older men, on the part of New York's urologic community. The overall postoperative complication rate was 18.5% and the mortality rate 1.3%. These rates are similar to those found in other series. Prostate cancer in older men usually has a protracted course. Radical prostatectomy in such men is associated with operative risks, and significant immediate and long-term complications. In addition, the procedure provides only marginal benefit of 10 years because of competing mortality in older men. The results of this study show a need for provider and patient focused educational efforts to reduce the numbers of radical prostatectomies in older men where the benefits are marginal compared to operative risks and significant immediate and long term complications.

Trends in the surgical treatment of prostate cancer in Wisconsin, 1989-1991.

Radical prostatectomy (removal of the prostate gland and seminal vesicles) is usually considered a definitive treatment for localized prostate cancer. Although a sharp increase and wide geographic variation in radical prostatectomy rates have been recently documented, the reasons for this increase and the factors that make men diagnosed with the disease more likely to be treated surgically are not well known. Our purpose was to examine trends in the use of surgical treatment for prostate cancer, as well as the factors associated with the choice of surgical treatment and how these factors changed in Wisconsin in the period 1989 through 1991. We carried out a population-based cohort study. A cohort of Wisconsin men diagnosed from 1989 through 1991 with prostate cancer was identified through the Wisconsin cancer reporting system. To determine which men diagnosed with prostate cancer were treated with surgery, we linked prostate cancer records to the Wisconsin hospital discharge database. The outcome measured was radical prostatectomy within 6 months from the date of the diagnosis of prostate cancer. The yearly number of prostate cancer cases reported from 1989 through 1991 rose 33%, from 2468 to 3278. During the same period, the yearly number of radical prostatectomies rose 226%, from 283 to 922. Patients diagnosed in 1991 were twice as likely to have surgery as those diagnosed in 1989, the proportion of cases receiving surgical treatment rising from 12% to 25%. Patients who were white, less than 65 years of age, had a cancer reported to be at regional stage, and who were first reported by large hospitals were more likely to be treated surgically. The use of surgery to treat prostate cancer has increased dramatically in Wisconsin, doubling in a 3-year period, despite the fact that studies have not shown surgery to be more effective than other options for many patients. The increase observed in the rate of surgery was about the same across age, race, stage at diagnosis, and hospital size. The reasons for this increase are probably multifactorial. Risks, costs, and benefits of surgical treatment should be carefully compared with those of alternative management approaches. Patients should be enabled to make an informed decision, based on the current best evidence, on the treatment option they prefer.

Changes in prostate cancer incidence and treatment in USA

SummaryWe examined time trends and geographical variations in the detection and treatment of prostate cancer in USA, based on information from white men aged 50 to 79 who resided in areas covered by the Surveillance, Epidemiology, and End Results (SEER) program of the United States National Cancer Institute. Prostate-cancer incidence and treatment rates were determined for the 9 population-based cancer registries which participate in the SEER program. Prostate-cancer mortality rates were assessed from data compiled by the National Center for Health Statistics. Prostate cancer incidence rates increased by 6·4% per year between 1983 and 1989. The increase appeared to be due to detection of early-stage disease; there was no increase in the incidence rate of metastatic cancer. Incidence rates varied widely among the SEER program areas: in 1989 from 267·9 per 100 000 in Connecticut to 606 8 in Seattle. Radical prostatectomy rates more than tripled between 1983 and 1989 in the SEER areas as a whole. Among men aged 70-79, the rate of prostatectomy increased by nearly 35% per year. There was a five-fold variation among SEER areas in radical prostatectomy rates in 1989, with a low of 43 4 per 100 000 in Connecticut and a high of 224·4 in Seattle. Prostate cancer mortality rates did not increase during the period of study; there was little variation among areas in prostate-cancer mortality rates, and no apparent correlation between the incidence and mortality rates for an area. Increases in rates of prostate cancer incidence and prostate surgery have occurred in the United States without clear evidence that screening and prostectomy are effective in reducing mortality. Moreover, much of the growth in incidence and radical prostatectomy rates has occurred among older men, who appear least likely to benefit from early detection and surgery of occult prostate cancer.

An Assessment of Radical Prostatectomy

Objectives. —To examine temporal trends and geographic variation in radical prostatectomy rates and short-term outcomes. Design. —Population-based study of radical prostatectomy for the years 1984 through 1990. Poisson regression was used to estimate temporal and regional effects. Setting. —The 50 states and the District of Columbia. Participants. —A 20% national sample of male Medicare beneficiaries aged 65 years or older. Main Outcome Measures. —Rate of radical prostatectomy; 30-day mortality; and major cardiopulmonary complications, vascular complications, or surgical repairs within 30 days of radical prostatectomy. Results. —A total of 10598 radical prostatectomies were identified. The adjusted rate of radical prostatectomy in 1990 was 5.75 times that in 1984. The relative increase was similar in all age groups. Substantial geographic variation existed in rates from 1988 through 1990: all states in the New England and Mid-Atlantic regions had rates equal to or below 60 per 100 000 male Medicare beneficiaries, while all states in the Pacific and Mountain regions had rates equal to or above 130 per 100 000. The mortality and morbidity after radical prostatectomy are not trivial for older men (aged 75 years and older)—almost 2% died and nearly 8% suffered major cardiopulmonary complications within 30 days of the operation. Conclusion. —The sharp increase and wide geographic variation in radical prostatectomy rates make the evaluation of this surgical procedure a pressing issue. The rising rate of radical prostatectomy among men aged 75 years and older merits special attention. ( JAMA . 1993;269:2633-2636)