EURURO Vol. 71 No. 5

736 844

prostate cancer, close follow-up and prompt initiation of
therapy for progression is paramount.
Our study has several limitations. Firstly, as these data
are derived from a large national patient database, the
possibility of miscoding and misclassification are present.
Additionally, as information was abstracted from medical
records, the accuracy of these data are dependent on the
completeness of such records. This fact may partially
explain why patients with higher comorbidities appear
more likely [37_TD$DIFF]to receive surgery, as such patients may have
had their comorbidities better captured. These limitations
also prevent accurate identification of patients who
received both EBRT and brachytherapy (such patients
would have been scored as receiving EBRT). Additionally,
for patients who received observation, we are unable to
determine whether they received watchful waiting or active
surveillance and are unable to comment on the extent of
their follow-up care. The retrospective nature of our study
also introduces the possibility of unidentified confounding
factors which may affect management choice. The NCDB is a
hospital-based cancer registry, not a population-based
registry, so these data may not be generalizable to the
entire USA population or populations outside of the USA.
However, demographic, clinical characteristics, and treat-
ment patterns for prostate and other cancers between the
NCDB and Surveillance, Epidemiology, and End Results
(SEER) database are remarkably similar. Regardless, our
study is the largest to date on this topic, including an order
of magnitude more patients than comparable studies reliant
on the CaPSURE or SEER databases. Issues with coding errors
related to prostate-specific antigen levels are already
suspected to be present in the SEER database and may also
affect the NCDB, though it is expected that the rate of such
errors are low
5. Conclusions
We have identified rapidly changing patterns of care in
patients with localized prostate cancer in the USA. While
rates of observation are increasing in low-risk disease,
receipt of RP has increased more substantially across all risk
groups. Utilization of radiation therapy is decreasing,
particularly brachytherapy whose use has declined by
nearly two-thirds over less than a decade. Socioeconomic
factors are strongly associated with management. Given the
lack of reliable data to suggest that one treatment for
prostate cancer is superior to another, all patients should be
counseled about their treatment options and be presented
with a full understanding of the side effects of therapy and
potential impacts on quality of life. Care must also be taken
to ensure that cost-conscious options such as surveillance
or brachytherapy are used appropriately . Further
work is also needed to ensure that disadvantaged popula-
tions have full access to care providers across the treatment
spectrum.
Author contributions: [38_TD$DIFF]Chun [39_TD$DIFF]Chieh [40_TD$DIFF]Lin had full access to all the data in the
study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Gray, Lin, Jemal, Efstathiou.
Acquisition of data: Lin, Jemal.
Analysis and interpretation of data: Gray, Lin, Jemal, Efstathiou.
Drafting of the manuscript: Gray, Lin, Jemal, Efstathiou.
Critical revision of the manuscript for important intellectual content: Gray,
Lin, Cooperberg, Jemal, Efstathiou.
Statistical analysis: Lin.
Obtaining funding: None.
Administrative, technical, or material support: Lin.
Supervision: Jemal, Efstathiou.
Other: None.
Financial disclosures: [41_TD$DIFF]Phillip J. Gray 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.
Funding/Support and role of the sponsor: American Cancer Society
intramural research funding assisted with the collection of the data.
Acknowledgments: This study used the limited dataset of the National
Cancer Database. The authors acknowledge the efforts of the American
College of Surgeons, the Commission on Cancer, and the American
Cancer Society in the creation of the National Cancer Database. The
American College of Surgeons and the Commission on Cancer have not
verified and are not responsible for the analytic or statistical
methodology employed, or the conclusions drawn from these data by
the authors. The interpretation and reporting of these data are the sole
responsibility of the authors.
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