Time Trends in Use of Radical Prostatectomy by Tumor Risk and Life Expectancy in a National Veterans Affairs Cohort

Importance: Guidelines endorse using tumor risk and life expectancy (LE) to select appropriate candidates for radical prostatectomy (RP), recommending against treatment of most low-risk tumors and men with limited LE. Objective: To investigate time trends in the use of RP by tumor risk and Prostate Cancer Comorbidity Index (PCCI) score in a contemporary, nationally representative Veterans Affairs (VA) cohort. Design, Setting, and Participants: This cohort study of 5736 men treated with RP at 8 VA hospitals from January 1, 2000, to December 31, 2017, used a nationally representative, multicenter sample from the VA SEARCH (Shared Equal Access Regional Cancer Hospital) database. Statistical analysis was performed from June 30, 2018, to August 20, 2020. Main Outcomes and Measures: Stratified linear and log-linear Poisson regressions were used to estimate time trends in the proportion of men treated with RP across American Urological Association tumor risk and PCCI (a validated predictor of LE based on age and comorbidities) subgroups. Results: Among 5736 men (mean [SD] age at surgery, 62 [6] years) treated with RP from 2000 to 2017, the proportion of low-risk tumors treated with RP decreased from 51% to 7% (difference, -44%; 95% CI, -50% to -38%). The proportion of intermediate-risk tumors treated with RP increased from 30% to 59% (difference, 29%; 95% CI, 23%-35%), with unfavorable intermediate-risk tumors increasing from 30% to 41% (difference, 11%; 95% CI, 4%-18%) and favorable intermediate-risk tumors decreasing from 61% to 41% (difference, -20%; 95% CI, -24% to -15%). The proportion of high-risk tumors treated with RP increased from 18% to 33% (difference, 15%; 95% CI, 9%-21%). Among men treated with RP, the proportion with the highest PCCI scores of 10 or more (ie, LE <10 years) increased from 4% to 13% (difference, 9%; 95% CI, 4%-14%). Within each tumor risk subgroup, no significant difference in the rate of tumors treated with RP over time was found across PCCI subgroups. Conclusions and Relevance: In this study, the use of RP shifted from low-risk and favorable intermediate-risk to higher-risk prostate cancer. However, its use among men with limited LE appears unchanged across tumor risk subgroups and increased overall..