Clinical Topics   /   Oncology

Imaging Guidelines Not Followed in Prostate Cancer

USM By U.S. Medicine
January 10, 2012

Clinicians are not adhering to imaging guidelines for men with incident prostate cancer, a recent study concluded.1

The researchers found that, of 18,491 men at low risk for prostate cancer, 45% received inappropriate imaging, while only 66% of 10,562 men at high risk received appropriate imaging.

“If you look at men who should not get scanned, 45% get a scan — 1 in 2 men who should not get scanned get one. In terms of the men who need to be scanned, only two-thirds of them are getting the scans that are guideline appropriate for them to get,” said study author Danil Makarov, assistant professor of Urology and Health Policy in the Department of Urology at New York University School of Medicine and attending urological surgeon at VA New York Harbor Healthcare System.

“Even though there are guidelines for imaging prostate cancer, they are being applied inconsistently,” he told U.S. Medicine.

Makarov and his colleagues wrote that, to their knowledge, the causes of “guideline-discordant imaging in this clinical setting are unknown.”

“According to several conceptual models, determinants of physician behavior may be generally classified as the characteristics of the external environment surrounding a healthcare organization, the healthcare organization itself, the clinical practice, the individual healthcare provider, the patient and the clinician-patient encounter.”

They stated, in this case, “the multiplicity of guidelines, poor initial physician education and lack of maintenance of knowledge might be plausible factors contributing to guideline-discordant care.”

Makarov said that, by following the guidelines, physicians can probably “improve the quality of care and save money at the same time.”

While several other studies show poor compliance with these guidelines, those studies were limited “by data lacking PSA measurements, which are critical to appropriate risk stratification, by data not representative of the American population or by the neglect of appropriate imaging for men at high risk,” according to the researchers.

For this current study, researchers did a cross-sectional study of men 66 to 85 years old who were diagnosed with prostate cancer in 2004 and 2005 using the National Cancer Institute Surveillance, Epidemiology and End Results (SEER)-Medicare database. This program includes data on cancer site, stage and histology for the 25% of the American population living in one of the SEER geographic areas. The PSA is also included in the database.

The researchers formed low risk and high-risk groups. They defined inappropriate imaging as any imaging for men at low risk and appropriate imaging as a bone scan for men at high risk, as well as pelvic imaging.

Makarov said that, while this particular study did not include VA patients, he is putting together a grant for a study to look at this issue in the VA.

This study received Yale University human investigation committee approval and was supported by the Veterans Health Administration and The Robert Wood Johnson Foundation.

  1. Makarov DV, Desai RA, Yu JB, Sharma R, Abraham N, Albertsen PC, Penson DF, Gross CP. The Population Level Prevalence and Correlates of Appropriate and Inappropriate Imaging to Stage Incident Prostate Cancer in the Medicare Population. J Urol. 2011 Nov 14. [Epub ahead of print] PubMed PMID: 22088337.

Study links BMI to cancer progression

A recent study suggests that obese men on androgen deprivation therapy (ADT) might be at increased risk for prostate cancer (PC) progression, but study authors say more research is needed.1

For the study, researchers carried out a retrospective review of 287 men in the SEARCH database treated with radical prostatectomy between 1988 and 2009.

The researchers found that, during a median 73-month follow-up after radical prostatectomy, 403 men (14%) received early ADT. Among 287 men with complete data, the median BMI was 28.3 kg/m2. The median follow-up from the start of ADT was 52 months, during which 44 men developed castration-resistant PC, 34 developed metastases and 24 died from PC. In multivariate analysis, a higher BMI was associated with a trend for greater risk of progression to castration-resistant PC, and an increased risk of developing metastases and a trend toward worse PC-specific mortality.

 “We found that men with higher body mass index were at increased risk of progression to castration-resistant prostate cancer, development of metastases and prostate-cancer-specific mortality. When we adjusted for various clinicopathological characteristics, obese men were at increased risk of progression to castration-resistant prostate cancer and development of metastases,” they wrote in the study abstract.

The researchers concluded that among men treated with early ADT, obese men may have increased risk of PC progression.

“These data support the general hypothesis that obesity is associated with aggressive PC, although validation of these findings and further study of the mechanisms linking obesity and poor PC outcomes are required,” the researchers wrote.

  1. Keto CJ, Aronson WJ, Terris MK, Presti JC, Kane CJ, Amling CL, Freedland SJ. Obesity is associated with castration-resistant disease and metastasis in men treated with androgen deprivation therapy after radical prostatectomy: results from the SEARCH database. BJU Int. 2011 Nov 17. doi: 10.1111/j.1464-410X.2011.10754.x. [Epub ahead of print] PubMed PMID: 22094083.

How Does Diabetes Influence Incidence, Progression of Prostate Cancer?

A recent study sought to understand the association between diabetes and positive prostate biopsy.1

While studies have shown a protective effect of diabetes mellitus (DM) on incidence of prostate cancer, the study researchers noted that the data are not consistent. In addition, they noted that it is not clear whether DM is associated with a positive result among patients referred for prostate biopsy due to abnormal PSA and/or abnormal digital rectal examination.

For the study, the researchers conducted a retrospective review of 3,162 consecutive men who underwent prostate biopsy between January 2000 and July 2009 at the Atlanta VA Medical Center. Men with positive and negative biopsies were compared for various demographic and clinical factors.

The researchers found that DM was associated with increased odds of positive biopsy in the overall cohort. Patients with DM had higher odds of more aggressive disease (Gleason 7) than those without the condition.

“In this large series of prostate biopsies, diabetes is associated with higher odds of positive biopsy and higher Gleason grade. More studies investigating the role of DM and its associated comorbidities in prostate carcinogenesis are needed,” the researchers concluded in the study abstract.

  1. Moses KA, Utuama OA, Goodman M, Issa MM. The association of diabetes and positive prostate biopsy in a US veteran population. Prostate Cancer Prostatic Dis. 2011 Sep 6. doi: 10.1038/pcan.2011.40. [Epub ahead of print] PubMed PMID: 21894176.

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