Variation in prostate cancer care at commission on cancer designated facilities

INTRODUCTION & OBJECTIVES: Contemporary treatment trends for prostate cancer show increased rates of active surveillance. However, nationwide applicability of these reports is limited. Additionally, the impact of Commission on Cancer facility type and the single facility on prostate cancer treatment patterns is unknown. MATERIAL & METHODS: We used the National Cancer Data Base between 2004 and 2013 to identify men diagnosed with loco-regional prostate cancer. The cohort was stratified based on the National Comprehensive Cancer Network prostate cancer risk-classes. Cochran-Armitage tests evaluated temporal trends. Random effects hierarchical logit models assessed treatment variation at Commission on Cancer-facility and institution level. RESULTS: In 825,707 men, utilization of radiation therapy declined and utilization of radical prostatectomy increased for all prostate cancer risk-groups between 2004-2013 (p\u3c0.0001). Observation for low-risk prostate cancer increased from 16.3% in 2004-2005 to 32.0% in 2012-2013 (p\u3c0.0001). Significant treatment variation was observed based on Commission on Cancer-facility type. for all riskgroups, rates of treatment according to facility type ranged from 28.4% to 76.9% for radical prostatectomy, 3.6% to 16.2% for brachytherapy, 13.7% to 28.1% for external beam radiation therapy, 1.3% to 7.3% for androgen deprivation therapy, 4.6% to 19.1% for observation, and 0% to 2.1% for cryotherapy. The highest rates of observation for low-risk disease were observed in academic centers. After adjusting for sociodemographic and facility factors, the highest proportions of treatment variation attributable to the single institution were observed for cryotherapy (59%, 95%CI 0.45-0.73) and brachytherapy (46%, 95%CI 38-53%), while the lowest proportion of treatment variation was observed for androgen deprivation therapy (14%, 95%CI 12-15%), and Observation (15%, 95%CI 14-17%). The results were consistent in the sensitivity analysis and in all National Comprehensive Cancer Network risk-groups. CONCLUSIONS: The increased utilization of observation in low-risk prostate cancer is an encouraging finding, which appears to be mainly derived by a decrease in radiotherapy utilization in this risk group. Regardless of tumor characteristics, significant variations in treatment modality exist among different facility types and institutions. Policy makers should address these variations to harmonize prostate cancer treatment

Variation in positive surgical margin status following radical prostatectomy for pT2 prostate cancer

Introduction & Objectives: Positive surgical margin (PSM)following radical prostatectomy for pT2 prostate cancer is considered a surgical quality metric. We evaluated patient, institutional, surgical approach and cancer-specific factors associated with PSM variability. Materials & Methods: A total of 45,426 men from 1,152 institutions with pT2 prostate cancer and known margin status following radical prostatectomy were identified using the National Cancer Database (2010-2015). Patient demographics and comorbidity, socioeconomic status, geographical and institutional information, cancer-specific variables and type of surgical approach were extracted. Multilevel hierarchical mixed effects logistic regression model was performed to determine the factors associated with a risk of PSM and their contribution to a PSM status. Results: Median PSM rate of 8.5% (IQR: 5.2-13.0%, range: 0-100%). Robotic (OR: 0.90, 95% CI: 0.83-0.99)and laparoscopic (OR: 0.74, 95% CI: 0.64-0.90)surgical approach, academic institution (OR: 0.87, 95% CI: 0.76-1.00), high institution surgical volume (\u3e297 cases [OR: 0.83, 95% CI: 0.70-0.99)and East North Central USA (OR: 0.71, 95% CI: 0.52-0.96)were independently associated with a lower PSM. Black men (OR: 1.13, 95% CI: 1.01-1.26)and adverse cancer specific features (PSA 10-20, PSA \u3e20, cT3 stage, Gleason 7, 8, 9-10; all p\u3e0.01)were independently associated with a higher PSM. The overall multilevel hierarchical logistic regression model accounts for 24.9% of PSM variation. Patient-specific, institution-specific and cancer-specific factors accounted for 9.1%, 15.6% and 61.1% of the variation within the overall regression model respectively. [Figure presented]Conclusions: Cancer-specific factors account for 15.2% of PSM variation with the remaining 84.8% of PSM variation due to patient, institution and other factors not accounted for in the model. Non cancer-specific factors represent potentially addressable factors which are important for policy makers in their efforts to improve patient outcome