title: Treatment patterns for older veterans with localized prostate cancer.
abstract: OBJECTIVE
  Concerns about over-treatment have led to practice guidelines discouraging active treatment of prostate cancer (PCa) in men with limited life expectancies and/or low-risk tumors. We evaluated treatment patterns for older veterans with localized PCa, particularly those with low-risk features.
  
  
  METHODS
  We used VA Cancer Registry data to identify men aged 65+ diagnosed with clinically localized PCa between January 1st, 2003 and December 31st, 2008. We obtained baseline data on demographics, tumor characteristics, comorbidities, and initial treatment within 6 months of diagnosis: radical prostatectomy, radiotherapy, primary androgen-deprivation therapy (PADT), or no active treatment. National VA surveys provided facility data, including academic affiliation, availability of oncologic specialists, and distance to radiotherapy facilities. Multinomial regression analyses determined associations between patient and facility characteristics and cancer treatment for men with localized (stage<III) and low-risk PCa (stage≤IIa, PSA<10ng/mL, Gleason ≤6).
  
  
  RESULTS
  17,206 veterans had localized PCa, 32% age 75+, 12% had comorbidity scores ≥3, and 33% had low-risk tumors. Overall, 39% received radiotherapy, 6% surgery, 20% PADT, and 35% no active treatment. For those with low-risk cancers, older men (RR=0.36, 95% CI 0.30-0.43) and sicker men (RR=0.75, 95% CI 0.62-0.90) were less likely to receive surgery or radiotherapy versus no active treatment. Over time, more of these men received no active treatment (from 41% to 57%, P<0.001) while fewer received PADT (from 11% to 4%, P<0.001).
  
  
  CONCLUSIONS
  VA treatment patterns followed evidence-based guidelines against treating older and sicker men with surgery or radiotherapy, for decreasing use of PADT, and for increasingly withholding active treatment, particularly for men with low-risk PCa.
authors.affiliation: Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA. Electronic address: richard-m-hoffman@uoiwa.edu.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Hoffman
authors.affiliation: San Francisco VA Medical Center, San Francisco, California, USA; Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA. Electronic address: Ying.Shi2@va.gov.
authors.forename: Ying
authors.initials: Y
authors.lastname: Shi
authors.affiliation: Urology Division, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA. Electronic address: stephen.freedland@cshs.org.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Freedland
authors.affiliation: Department of Health Care Policy, Harvard Medical School, and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. Electronic address: keating@hcp.med.harvard.edu.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Keating
authors.affiliation: San Francisco VA Medical Center, San Francisco, California, USA; Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA. Electronic address: louise.walter@ucsf.edu.
authors.forename: Louise C
authors.initials: LC
authors.lastname: Walter
mesh_terms: D000368:Aged; D000726:Androgen Antagonists / Q000627:therapeutic use; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011468:Prostatectomy / Q000706:statistics & numerical data; D011471:Prostatic Neoplasms / Q000473:pathology / Q000628:therapy*; D011878:Radiotherapy / Q000706:statistics & numerical data; D014728:Veterans; D057832:Watchful Waiting / Q000706:statistics & numerical data
chemical_list: D000726:Androgen Antagonists
keywords: Aged; Physician’s practice patterns; Prostatectomy; Prostatic neoplasms; Radiotherapy; Watchful waiting