Surgical versus Medical Castration for Metastatic Prostate Cancer: Use and Overall Survival in a National Cohort - Beyond the Abstract

The past few years have seen remarkable advances for men with metastatic prostate cancer in terms of systemic therapies. These advances will not only lead to improved outcomes for men with metastatic prostate cancer but will also undoubtedly lead to more healthcare costs and morbidity related to treatment side effects as these men live longer.

Surgical castration in the form of bilateral orchiectomy is the oldest targeted cancer therapy and recent data has suggested, compared to medical castration (conventional androgen deprivation), surgery has fewer adverse effects. These include a lower risk of fractures, peripheral arterial disease, and cardiac events. Additionally, over time, the cost of surgical castration is lower than that of medical castration due to the requisite re-dosing of medical castration. Finally, for patients whose physicians may have concerns regarding medical compliance related to barriers to healthcare access, surgical castration is a permanent form of castration that can help mitigate those concerns. However, in the late 1990s and early 2000s, the use of medical castration increase with some studies showing a correlation with insurance reimbursements.

We sought to look at current trends in surgical castration. We used a national cancer registry in the United States which captures data on over 50% of new prostate cancer cases every year from 2004 to 2016. We were able to identify over 24,000 men with metastatic prostate cancer at the time of diagnosis. Within this group, only about 5% received surgical castration and the use of surgery declined from about 8% in 2004 to about 3% in 2016. Men with Medicaid or no insurance were more likely to get surgery compared to those with Medicare insurance. Men living in regions of higher income were less likely to get surgery. We also showed, after adjusting for relevant factors, men have similar overall survival following diagnosis regardless of surgical or medical castration.

Thus, in a contemporary cohort, surgical castration is low and decreasing. Meanwhile, castration type is not associated with differences in survival. Given surgical castration may be associated with fewer adverse effects, lower costs, and better medical compliance compared to medical castration, increasing the overall use of surgical castration may reduce healthcare costs and medication side effects for men with metastatic prostate cancer without compromising oncologic outcomes.

These results likely won’t surprise most physicians who care for men with metastatic prostate cancer. Many would suggest men don’t want surgery for several reasons including cosmetic outcomes. However, further work is needed to fully understand what individual patient and provider factors affect which form of castration is ultimately chosen. If those factors can be identified, interventions to increase surgery may have significant benefits for patients. If required, future efforts should change financial incentives to encourage physicians to advocate for more surgical castration. We hope this study brings greater attention to this topic for men with metastatic prostate cancer.

Written by: Adam B. Weiner, MD, Gregory B. Auffenberg, MD, MS, Department of Urology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA.

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