Health Affairs Population , But Not Among Diagnosed Men Sharp Decline In Prostate Cancer Treatment Among Men In The General

The indolent nature of many prostate cancers has heightened concerns that harms from treatment may outweigh those from the disease and has resulted in a growing consensus in favor of less aggressive screening and treatment. We sought to understand the population-level impact of this consensus on the treatment of prostate cancer. Using national Medicare data for the period 2007–12, we assessed treatment rates among men with newly diagnosed prostate cancer. We identified both population-based rates (which are sensitive to changes in diagnosis and treatment patterns) and rates among diagnosed men (which are sensitive only to changes in treatment patterns). We also assessed trends in treatment among men with a high risk of noncancer mortality, who are unlikely to benefit from treatment. Population-based treatment rates declined by 42 percent, while rates among diagnosed men declined by only 8 percent. Treatment rates among men with the highest noncancer mortality risk and regional variation were unchanged. These results suggest that decreasing rates of diagnosis, changing attitudes, and guidelines calling for reduced prostate-specific antigen screening, not changes in practice patterns among specialists treating diagnosed men, drove the decline in population-based treatment rates. Compared to policies that emphasize volume, those that emphasize value in specialty care have the potential to exert stronger effects on practice patterns. H istorically, there has been widespread variation in the treatment of prostate cancer, largely a result of uncertainty about who needs treatment. Because of the indolent nature of some prostate cancers, many men die with the disease, not from it. In 2009, findings from two large randomized trials cast doubt on the utility of prostate-specific antigen (PSA) screening and served as the basis of subsequent recommendations against routine PSA screening in all men by the US Preventive Services Task Force. The first recommendation, based on data from observational trials between 2002 and 2007, was issued in 2008 and advised against routine screening in men older than age seventy-five. It was followed by a highly publicized draft recommendation against all PSA screening in 2011, which was finalized in 2012. At the core of the task force’s recommendations are the harms associated with diagnosis and treatment and concerns about potential overtreatment. Recognition that widespread PSA screening leads to the detection of some cases of clinically indolent disease prompted the American Urological Association in 2013 to modify its professional guidelines to recommend less frequent doi: 10.1377/hlthaff.2016.0739