Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer. Comparative Effectiveness Review, Number 13

摘要

Prostate cancer is the most common nondermatologic cancer in men. In 2007 an estimated 218,890 men were diagnosed with, and 27,050 deaths were attributed to, prostate cancer in the United States. Approximately 90 percent of men with prostate cancer have disease considered confined to the prostate gland (clinically localized disease). Reported prostate cancer incidence has increased with introduction of the prostate-specific antigen (PSA) blood test. Diseasespecific mortality rates have declined, and an estimated 1.8 million men living in the United States have a diagnosis of prostate cancer. Clinically detected prostate cancer is primarily a disease of elderly men. Prostate cancer frequently has a relatively protracted course even if left untreated, and many men die with, rather than from, prostate cancer. Largely because of widespread PSA testing, the lifetime risk of being detected with prostate cancer in the United States has nearly doubled to 20 percent. However, the risk of dying of prostate cancer has remained at approximately 3 percent. Therefore, considerable overdetection and treatment may exist. The primary goal of treatment is to target the men most likely to need intervention in order to prevent prostate cancer death and disability while minimizing intervention-related complications. Common treatments include watchful waiting (active surveillance), surgery to remove the prostate gland (radical prostatectomy), external beam radiotherapy (EBRT) and interstitial radiotherapy (brachytherapy), freezing the prostate (cryotherapy), and androgen deprivation therapy (ADT). (Treatment options are outlined in Table A.) All treatments have risks of complications, although frequency and severity may vary. Patient treatment decisionmaking incorporates physician recommendations and estimated likelihood of cancer progression without treatment, as well as treatment-related convenience, costs, and potential for eradication and adverse effects (AEs). Patient characteristics, including race/ethnicity, age, and comorbidities, have an important role in predicting mortality; the likelihood of treatment-related urinary, bowel, and sexual dysfunction; treatment tradeoff preferences; and selection. However, little is known about how these characteristics modify the effect of treatment.