Assessment of the Rate of Adherence to International Guidelines for Androgen Deprivation Therapy with External-beam Radiation Therapy: A Population-based Study

Eur Urol. 2016 Sep;70(3):429-35. doi: 10.1016/j.eururo.2016.02.057. Epub 2016 Mar 4.

Abstract

Background: The National Comprehensive Cancer Network and the European Association of Urology guidelines recommend using radiation therapy (RT) with androgen deprivation therapy (ADT) to treat high-risk and locally advanced prostate cancer patients.

Objective: To evaluate the degree of adherence to these guidelines.

Design, setting, and participants: Between 2003 and 2009, in the Surveillance Epidemiology and End Results (SEER)-Medicare database, 14 180 patients were diagnosed with high-risk (T1-T2 with World Health Organization histologic grade 3) or locally advanced (T3-T4 with any histologic grade) prostatic adenocarcinoma.

Intervention: Administration of RT-ADT versus RT alone.

Outcome measurements and statistical analysis: We assessed the rate of adherence to guidelines with respect to use of RT-ADT in the overall population and after stratification according to stage-grade groupings (T1-T2 G3 vs T3-T4 any grade), age (66-69, 70-74, 75-79, ≥80 yr), Charlson Comorbidity Index (CCI) (0, 1, ≥2), and preexisting baseline cardiovascular (CV) disease. We depicted the rate of RT-ADT administration graphically over the study period. Multivariable logistic regression analyses were performed to assess the predictors of RT-ADT use.

Results and limitations: RT-ADT rates and guideline adherence were 58-75%, with the highest rate (75%) in 2003 and the lowest (58%) in 2009. When stratified according to stage-grade groupings, age, CCI, and preexisting baseline CV disease, similar results were obtained. In multivariable analyses, year of diagnosis (p<0.001), patient age (p<0.001), stage-grade groupings (p<0.001), CCI (p=0.036), race (p<0.001), marital status (p<0.001), population density (p<0.001), and US regions (p<0.001) were independent predictors of RT-ADT use. The limitations of our study include age >65 yr and exclusive Medicare coverage.

Conclusions: The rate of guideline adherence regarding the use of RT-ADT is suboptimal and decreases with time instead of increasing.

Patient summary: This population-based study provides evidence of low adherence to international urologic guidelines regarding the combination of radiation therapy (RT) with androgen deprivation therapy (ADT) for high-risk and locally advanced prostate cancer (PCa) patients. Despite the increasing number of randomized controlled trials over time that showed a survival benefit for patients with high-risk and locally advanced PCa treated with RT-ADT compared with RT alone, the rate of adherence to guidelines decreased with time.

Keywords: High-risk prostate cancer; Locally advanced prostate cancer; RT-ADT; SEER-Medicare.

MeSH terms

  • Adenocarcinoma / secondary
  • Adenocarcinoma / therapy*
  • Age Factors
  • Aged
  • Aged, 80 and over
  • Androgen Receptor Antagonists / administration & dosage
  • Antineoplastic Combined Chemotherapy Protocols / therapeutic use*
  • Chemotherapy, Adjuvant
  • Comorbidity
  • Gonadotropin-Releasing Hormone / agonists
  • Guideline Adherence / statistics & numerical data*
  • Humans
  • Male
  • Marital Status
  • Medicare
  • Neoplasm Grading
  • Neoplasm Staging
  • Population Density
  • Practice Guidelines as Topic
  • Prostatic Neoplasms / pathology*
  • Prostatic Neoplasms / therapy*
  • Racial Groups
  • Radiotherapy*
  • SEER Program
  • United States

Substances

  • Androgen Receptor Antagonists
  • Gonadotropin-Releasing Hormone