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Trends in initial management of prostate cancer in New Hampshire - Reasons for optimism?
Johann P. Ingimarsson, MD1, Maria O. Celaya, MPH, CTR2, Michael Laviolette, PhD, MPH3, Judith R. Rees, BM,BCh,MPH,PhD4, Elias S. Hyams, MD1.
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 2New Hampshire State Cancer Registry, Lebanon, NH, USA, 3New Hampshire Division of Public Health Services, Concord, NH, USA, 4Geisel School of Medicine, Hanover, NH, USA.

BACKGROUND: Various refinements have been suggested to the management of prostate cancer to minimize over- and under treatment. Expectant management/active surveillance strategies have been encouraged for low risk disease, and definitive treatment for high risk cancer, often with surgery rather than default radiation therapy, to maximize potential cure. In this study, we assess whether statewide trends in management of different disease risk categories reflect appropriate management of these patients.
METHODS: Men diagnosed with clinically localized prostate cancer from 2004 to 2011 in the New Hampshire State Cancer Registry were identified. Patient with recorded clinical stage, Gleason score and PSA value were included and classified according to the D’Amico criteria. Patients with nodal or distant metastasis on clinical staging were excluded. Initial treatment modality was recorded as ‘surgery’, ‘radiation’, ‘expectant management’ or ‘hormones only’. Temporal trends were assessed by chi square for trend.
RESULTS: During the study period, 6203 met all inclusion criteria. 2302 (34%), 1997 (30%) and 1904 (28%) were diagnosed with low, intermediate and high risk disease, respectively. For patients with low risk disease, there was increased use of expectant management (17 to 42%, p<0.001) and surgery (29 to 39%, p<0.001) as initial treatment but decreased use of radiation therapy (49 to 19%, p<0.001). For intermediate risk patients, surgery was used more frequently (24 to 50%, p<0.001) while radiation therapy less frequently (58 to 34%, p<0.001). Hormonal therapy alone was rarely used in low (2%) or intermediate (4%) risk disease. For high risk patients, surgery utilization increased (38 to 47%, p=0.003) and radiation therapy decreased (41 to 38%, p=0.026), while hormonal therapy and expectant management remained stable at 8 and 14%, respectively.
CONCLUSIONS:
Encouraging trends in the management clinically localized prostate cancer in New Hampshire include less potential overtreatment of low risk cancer, and rising utilization of surgery for high risk disease. Continued efforts to study and refine practice patterns will enable us to optimize our approaches to this heterogeneous disease.


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