title: The prostate cancer conundrum revisited: treatment changes and prostate cancer mortality declines.
abstract: BACKGROUND
  Prostate cancer mortality rates in the United States declined by >40% between 1991 and 2005. The impact of changes in primary treatment and adjuvant and neoadjuvant hormone therapy on this decline is unknown.
  
  
  METHODS
  The authors applied 3 independently developed models of prostate cancer natural history and disease detection under common assumptions about treatment patterns, treatment efficacy, and survival in the population. Primary treatment patterns were derived from the Surveillance, Epidemiology, and End Results registry; data on the frequency of hormone therapy were obtained from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database; and treatment efficacy was based on estimates from randomized trials and comparative effectiveness studies of treatment alternatives. The models projected prostate cancer mortality without prostate-specific antigen screening and in the presence and absence of treatment benefit. The impact of primary treatment was expressed as a fraction of the difference between observed mortality and projected mortality in the absence of treatment benefit.
  
  
  RESULTS
  The 3 models projected that changes in treatment explained 22% to 33% of the mortality decline by 2005. These contributions were accounted for mostly by surgery and radiation therapy, which increased in frequency until the 1990s, whereas hormone therapies contributed little to the mortality decline by 2005. Assuming that treatment benefit was less for older men, changes in treatment explained only 16% to 23% of the mortality decline by 2005.
  
  
  CONCLUSIONS
  Changes in primary treatment explained a minority of the observed decline in prostate cancer mortality. The remainder of the decline probably was because of other interventions, such as prostate-specific antigen screening and advances in the treatment of recurrent and progressive disease.
authors.affiliation: Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA. retzioni@fhcrc.org
authors.forename: Ruth
authors.initials: R
authors.lastname: Etzioni
authors.forename: Roman
authors.initials: R
authors.lastname: Gulati
authors.forename: Alex
authors.initials: A
authors.lastname: Tsodikov
authors.forename: Elisabeth M
authors.initials: EM
authors.lastname: Wever
authors.forename: David F
authors.initials: DF
authors.lastname: Penson
authors.forename: Eveline A M
authors.initials: EA
authors.lastname: Heijnsdijk
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Katcher
authors.forename: Gerrit
authors.initials: G
authors.lastname: Draisma
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Feuer
authors.forename: Harry J
authors.initials: HJ
authors.lastname: de Koning
authors.forename: Angela B
authors.initials: AB
authors.lastname: Mariotto
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006801:Humans; D008297:Male; D008875:Middle Aged; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000097:blood / Q000401:mortality* / Q000628:therapy*; D018426:SEER Program
chemical_list: D017430:Prostate-Specific Antigen