IMPORTANCEPatients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects.OBJECTIVE To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance. DESIGN, SETTING, AND PARTICIPANTSPopulation-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015.EXPOSURES Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance. MAIN OUTCOMES AND MEASURESQuality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains-sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems-each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point. RESULTSOf 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI,.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI,) and brachytherapy (20.5 [95% CI,.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains.CONCLUSIONS AND RELEVANCE In this cohort of men with localized prostate cancer, each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.

There was low use of cancer-directed treatment at the end of life for younger cancer patients, and hospice use was higher than 50%. However, there was a relatively high utilization of hospital-based care. These results demonstrate an opportunity for continued improvements in the provision of high-value, patient-centered care at the end of life.

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BACKGROUND Stereotactic body radiotherapy (SBRT) is a newer treatment option for patients with localized prostate cancer. The rates of diffusion of this technology across the United States are unknown. The goal of the current study was to describe the use of SBRT among patients with prostate cancer based on different risk groups (low, intermediate, or high risk) and by type of facility (community cancer program, comprehensive community cancer program, or academic program) in which patients were treated. METHODS Using the National Cancer Data Base, a national registry that contains approximately 70% of patients with cancer in the United States, the authors identified 274,466 men between the ages of 40 to 80 years who were diagnosed from 2004 to 2012 with localized prostate cancer and received radiation therapy (RT) as their initial treatment. The authors described the prevalence of SBRT use each year, and multivariable analysis was used to examine factors associated with the receipt of SBRT. RESULTS In 2004, SBRT use was low (<1% in all patient groups), and was observed to increase steadily each year. By 2012, 8.8% of low‐risk patients treated at academic centers with RT received SBRT. Uptake of SBRT was highest in patients with low‐risk or intermediate‐risk disease. Multivariable analysis demonstrated that year of diagnosis, type of center, risk group, and race were all significantly associated with the use of SBRT. CONCLUSIONS To the authors' knowledge, the current study is the first report of the adoption of SBRT for localized prostate cancer across the United States. Diffusion was noted to be slowest at community cancer programs, reflecting potential barriers of cost or expertise for this new technology. Adoption of SBRT was found to be highest among patients with low‐risk or intermediate‐risk disease, in accordance with the bulk of patients included in published SBRT studies. Cancer 2016;122:2234–41. © 2016 American Cancer Society.

There is substantial cost to the Medicare program associated with the diagnosis and treatment of localized prostate cancer among elderly men in the United States, despite the fact that these men are unlikely to die of prostate cancer. The majority of costs are related to treatment. Reducing provision of low-value health care services among this patient population could result in significant health care savings.

Limited information is currently available about medication adherence for common chronic conditions among the Medicaid population. The primary objective of this study was to assess medication adherence among Medicaid recipients with depression, diabetes, epilepsy, hypercholesterolemia, and hypertension. Factors influencing adherence were determined. The authors also assessed whether adherence influences the utilization of acute care services. The target population included nonelderly adult recipients (ages 21-64 years) who were continuously enrolled in the Mississippi (MS) Medicaid fee-for-service program from January 1, 2006 to December 31, 2007. Recipients were identified who had a medical services claim with a diagnosis of depression, diabetes, epilepsy, hypercholesterolemia, or hypertension in calendar year 2006. Within each chronic disease sample, medication adherence was determined using calendar year 2007 data for recipients who met inclusion and exclusion criteria. Recipients with adherence ≥80% were classified as adherent. Logistic regression analyses were used to determine the factors that predict medication adherence and the effect of adherence on concurrent all-cause acute care service (ie, hospitalization, emergency room visit) utilization. Approximately 24% of recipients with depression, 35.9% with diabetes, 53.6% with epilepsy, 32% with hypercholesterolemia, and 42.2% with hypertension were adherent. Within each chronic disease sample, males and whites had higher adherence than females and blacks. After controlling for demographic and disease-related covariates, recipients who were adherent had lower concurrent acute care service utilization than nonadherent recipients. Given the inverse relationship between adherence and acute care service utilization, policy makers should consider implementing educational interventions aimed at improving adherence in this underprivileged population.

Background Prostate cancer racial disparities in mortality outcomes are the largest in all of oncology, and less aggressive treatment received by African American (AA) patients versus white patients is likely a contributing factor. However, the reasons underlying the differences in treatment are unclear. Methods This study examined a prospective, population‐based cohort of 1170 men with newly diagnosed nonmetastatic prostate cancer enrolled from 2011 to 2013 before treatment throughout North Carolina. By phone survey, each participant was asked to rate the aggressiveness of his cancer, and his response was compared to the actual diagnosis based on a medical record review. Participants were also asked to rate the importance of 10 factors for their treatment decision‐making process. Results Among AA and white patients with low‐risk cancer (according to National Comprehensive Cancer Network guidelines), 78% to 80% perceived their cancers to be “not very aggressive.” However, among high‐risk patients, 54% of AA patients considered their cancers to be “not very aggressive,” whereas 24% of white patients did (P < .001). Although both AA and white patients indicated that a cure was a very important decision‐making factor, AAs were significantly more likely to consider cost, treatment time, and recovery time as very important. In a multivariable analysis, perceived cancer aggressiveness and cure as the most important factor were significantly associated with receiving any aggressive treatment and were associated with surgery (vs radiation). After adjustments for these factors and sociodemographic factors, race was not significantly associated with the treatment received. Conclusions Racial differences in perceived cancer aggressiveness and factors important in treatment decision making provide novel insights into reasons for the known racial disparities in prostate cancer as well as potential targets for interventions to reduce these disparities.

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