Overall Survival in Patients with Localized Prostate Cancer in the US Veterans Health Administration: Is PIVOT Generalizable?

Abstract

A better understanding of overall survival among patients with clinically localized prostate cancer (PCa) in the US Veterans Health Administration (VHA) is critical to inform PCa treatment decisions, especially in light of data from the Prostate Intervention Versus Observation Trial (PIVOT). We sought to describe patterns of survival for all patients with clinically localized PCa treated by the VHA. We created an analytic cohort of 35 954 patients with clinically localized PCa diagnosed from 1995 to 2001, approximating the PIVOT inclusion criteria (age of diagnosis ≤75 yr and clinical stage T2 or lower). Mean patient age was 65.9 yr, and median follow-up was 161 mo. Overall, 22.5% of patients were treated with surgery, 16.6% were treated with radiotherapy, and 23.1% were treated with androgen deprivation. Median survival of the entire cohort was 14 yr (25th, 75th percentiles, range: 7.9-20 yr). Among patients who received treatment with curative intent, median survival was 17.9 yr following surgery and 12.9 yr following radiotherapy. One-third of patients died within 10 yr of diagnosis compared with nearly half of the participants in PIVOT. This finding sounds a note of caution when generalizing the mortality data from PIVOT to VHA patients and those in the community.

Patient summary: More than one-third of patients diagnosed with clinically localized prostate cancer treated through the US Veterans Health Administration from 1995 to 2001 died within 10 yr of their diagnosis. Caution should be used when generalizing the estimates of competing mortality data from PIVOT.

Keywords: Competing risks of mortality; Prostate cancer; Survival; Veterans Health Administration.

Conflict of interest statement

Financial disclosures: John T. Leppert certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Published by Elsevier B.V.

Figures

Fig. 1

The primary treatment of clinically localized prostate cancer in the US Veterans Health Administration from 1995 to 2001. The total number of patients (n = 35 954) with clinically localized prostate cancer is plotted by patient age and treatment type. Surgery was the most common treatment among men aged <60 yr (2626, 42.8%) and declined steadily among men aged 60–69 yr (4509, 26.2%) and 70–75 yr (938, 7.4%). The percentage of men receiving radiotherapy increased slightly with increasing patient age (6.5% for age <50 yr, 12.7% for 50–59 yr, 17.2% for 60–69 yr, 18.0% for 70–75 yr). The number and percentage of patients treated with androgen deprivation therapy increased with patient age (11.7% for age <50 yr, 14.8% for 50–59 yr, 21.0% for 60–69 yr, 30.2% for 70–75 yr). Conservative therapy also increased with increasing patient age (30.3% for age <50 yr, 30.7% for 50–59 yr, 35.6% for 60–69 yr, 44.4% for 70–75 yr). Conservative management was the most common treatment for men aged >60 yr (39.3%).

Fig. 2

The overall survival of patients with clinically localized prostate cancer in the US Veterans Health Administration stratified by patient age. (a) Survival decreased with increasing patient age. (b) Patients treated with surgery had the best survival. (c) Despite the selection of younger— and likely healthier—patients for surgery, 21% of patients had died after 10 yr of follow-up. (d) Median survival for patients treated with radiotherapy was 12.9 yr, whereas 36.7% of patients had died after 10 yr. (e) Median survival for patients treated with androgen deprivation therapy was 11.7 yr, whereas 57.3% of patients had died after 10 yr. (f) Median survival for patients receiving conservative management was 13.9 yr, whereas 34.8% of patients had died after 10 yr.