Factors associated with initial therapy for clinically localized prostate cancer: Prostate cancer outcomes study

Background: Because of the lack of results from randomized clinical trials comparing the efficacy of aggressive therapies with that of more conservative therapies for clinically localized prostate cancer, men and their physicians may select treatments based on other criteria. We examined the association of sociodemographic and clinical characteristics with four management options: radical prostatectomy, radiation therapy, hormonal therapy, and watchful waiting. Methods: We studied 3073 participants of the Prostate Cancer Outcomes Study diagnosed from October 1, 1994, through October 31, 1995, with clinically localized disease (T1 or T2). Participants completed a baseline survey, and diagnostic and treatment information was abstracted from medical records. Multiple logistic regression analysis identified factors associated with initial treatment. All statistical tests were two-sided. Results: Patients with clinically localized disease received the following treatments: radical prostatectomy (47.6%), radiation therapy (23.4%), hormonal therapy (10.5%), or watchful waiting (18.5%). Men aged 75 years or older more often received conservative treatment (i.e., hormonal therapy alone or watchful waiting; 57.9% of men aged 75-79 years and 82.1% of men aged 80 years and older) than aggressive treatment (i.e., radical prostatectomy or radiation therapy) (for all age groups, P less than or equal to .001). After adjustment for age, clinical stage, baseline prostate-specific antigen level, and histologic grade, the following factors were associated with conservative treatment: history of a heart attack, being unmarried, geographic region, poor pretreatment bladder control, and impotence. In men younger than 60 years, use of aggressive treatment was similar by race/ethnicity (adjusted percentages = 85.5%, 88.1%, and 85.3% for white, African-American, and Hispanic men, respectively). However, among men 60 years old and older, African-American men underwent aggressive treatment less often than did white men or Hispanic men (adjusted percentages for men aged 60-64 years = 67.1%, 84.7%, and 79.2%, respectively; 65-74 years = 64.8%, 73.4%, and 79.5%, respectively; and 75 years old and older = 25.2%, 45.7%, and 36.6%, respectively). Conclusions: The association of nonclinical factors with treatment suggests that, in the absence of definitive information regarding treatment effectiveness, men diagnosed with prostate cancer should be better informed of the risks and benefits of all treatment options.