Physician Study: CoC Standard 4.6 - 2018 Monitoring Compliance with National Evidence Based Guidelines for Prostate Cancer

Background

The American Cancer Society’s estimates for prostate cancer in the United States for 2018 are 164,690 new cases and 29,430 deaths. One out of nine men will be diagnosed with prostate cancer during his lifetime. Prostate cancer develops mainly in older men and in African-American men—approximately six out of ten cases are diagnosed in men aged 65 or older. It is rare to be diagnosed before the age of 40 with the average age of diagnosis being 66. Prostate cancer is the second leading cause of cancer death in American men behind lung cancer. About one man in forty-one will die of prostate cancer. Although prostate cancer can be a serious disease, most men diagnosed do not die from it. More than 2.9 million men in the US who have been diagnosed with prostate cancer at some point are still alive today.

National guidelines for treatment:

The Medical Center follows evidence-based national treatment guidelines for determining treatment based on stage of disease as found in the National Comprehensive Care Network (NCCN). These guidelines are site-specific and based on a number of presenting factors and stage of cancer at presentation and recurrence.

For patients with prostate cancer, treatment options depend on stage, patient preferences, and life expectancy. In general, treatment options by stage include:

•    Stage 1—Active surveillance, observation, radical prostatectomy, and radiation therapy;
•   Stage 2A—Observation, radical prostatectomy and radiation therapy +/- hormone therapy;
•   Stage 2B—Radical prostatectomy, radiation therapy and hormonal therapy;
•   Stage 3—Radical prostatectomy, radiation therapy, and hormonal therapy;
•   Stage 4—Systemic therapy +/- radiation therapy in select patients.

For patients who have high risk factors after prostatectomy, including extra-capsular invasion, seminal vesicle invasion, positive margins, or a rising PSA, the addition of pelvic irradiation to the prostate bed improves survival. For the patients who elect radiation therapy, the addition of hormone therapy reduces the rate of recurrence and improves survival in patients with stages 2-3 prostate cancer.

Population: The Medical Center prostate cases

In 2016 and 2017, there were 139 analytic prostate cases. To perform a more focused study, we examined the 22 cases that had stage III prostate cancer. Evaluated patients received the recommended treatment of radical prostatectomy, radiation therapy, and/or hormone therapy according to NCCN guidelines.

All patients had the appropriate workup including digital rectal exam, PSA, prostate biopsy, and family history. Life expectancy was not documented in the charts of the selected patients. Treatment allotted assumed a life expectancy of greater than 5 years. Clinical/pathologic features categorized as high/very high risk group included T3a, T3b, or T4, Gleason’s score of 8-9 or Gleason pattern 5, and/or a PSA greater than 20 ng/mL.

A total of 18 patients underwent radical prostatectomy with 9 patients receiving only radical prostatectomy, 4 patients receiving radical prostatectomy plus radiation therapy, and 5 patients receiving radiation therapy and hormone therapy. Four patients received radiation therapy without surgery with 2 of those patients also receiving hormonal therapy.

All patients had the histology of adenocarcinoma. The average age was 66 in the age range of 54 to 86 years old. There were 21 white men diagnosed and 1 black male.

Summary

Based on available data, 22 patients with stage III prostate cancer were treated at The Medical Center and were treated according to NCCN guidelines. All patients received radical prostatectomy or radiation therapy alone or had a combination of surgery with the addition of radiation therapy and/or hormone therapy.

Recommendations

There were no areas of concern with regard to the first course of therapy for stage III prostate cancer at The Medical Center.

Resources

NCCN Guidelines, Version 4.2018, Prostate Cancer; CPDMS; American Cancer Society