An analysis of data on prostate cancer from the National Cancer Database has found that the use of brachytherapy—a safe and cost-effective treatment method—is in steady decline.1
Examining data for more than 1.5 million patients diagnosed with localized prostate cancer from 1998 through 2010, researchers from Fox Chase Cancer Center in Philadelphia, PA, found that, overall, 13.4% were treated with brachytherapy, compared with 49.8% treated with surgery, 26.3% with other forms of radiation, 24.1% with hormone therapy, and 7.8% with no treatment.
“Prior studies had shown that brachytherapy utilization was increasing in the late 1990s, but given the introduction of robotic prostatectomy and the expanded use of intensity-modulated radiation therapy, there is a lot of competition for the treatment of patients with localized prostate cancer,” said lead author Jeffrey M. Martin, MD, MS, who is radiation oncology chief resident at Fox Chase Cancer Center. “We were looking to see if this prior trend had changed and found that it had changed quite significantly.”
Use of brachytherapy reached a peak of 17% of patients with localized prostate cancer in 2002, and then declined steadily to a low of 8% in 2010. Use of surgery increased from 46% in 1998 to 59% in 2010, while use of other forms of radiotherapy remained unchanged.
The greatest decline in the use of brachytherapy occurred among low-risk patients, who were more likely to receive either surgery or no treatment.
Patient demographics played an important role in choice of therapy: patients were less likely to receive brachytherapy if they were Hispanic or on Medicaid or received care in an urban setting. As patients aged and went on Medicare, they became more likely to receive brachytherapy.
Effective and Inexpensive, But Often Overlooked
Reasons for the decline in the use of brachytherapy are unclear, but appear to be related to the increased use of robotic laparoscopy after its introduction in the early 2000s.
Financial considerations may play an important role as well. “For a radiation oncologist, brachytherapy is a time- and resource-intensive procedure, requiring the physician to be there for the entire treatment and requiring the use of general anesthesia,” Dr. Martin said. “It is possible that radiation oncologists are preferring external beam radiation to treat patients since it allows them to see more patient volume.”
Whatever the reason for the decline in the use of brachytherapy, it is not because it is ineffective. Numerous studies with up to 12 years of follow-up have demonstrated excellent disease-specific and overall survival for patients with prostate cancer treated with brachytherapy, particularly those at low risk.2,3
Brachytherapy is also the least expensive initial treatment for prostate cancer (other than watchful waiting)4 and the decline in its use has potentially serious implications for public health policy. “Given the current emphasis on the importance of value in health care reform, we hope that the trend will reverse and brachytherapy utilization will comprise a larger proportion of treatments,” Dr. Martin said.
- Martin JM, Handorf EA, Kutikov A, et al. The rise and fall of prostate brachytherapy: use of brachytherapy for the treatment of localized prostate cancer in the National Cancer Data Base. Cancer. 15 Apr 2014. DOI: 10.1002/cncr.28697 [Epub ahead of print]
- Grimm P, Billiet I, Bostwick D, et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJU Int. 2012;109(suppl 1):22-29.
- Taira AV, Merrick GS, Butler WM, et al. Long-term outcome for clinically localized prostate cancer treated with permanent interstitial brachytherapy. Int J Radiat Oncol Biol Phys. 2011;79(5):1336-1342.
- Hayes JH, Ollendorf DA, Pearson SD, et al. Observation versus initial treatment for men with localized, low-risk prostate cancer: a cost-effectiveness analysis. Ann Intern Med. 2013;158(12):853-860.