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A Population-Based Study on Radical Prostatectomy in France

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A Population-Based Study on Radical Prostatectomy in France Prostate Cancer and Prostatic Diseases (2001) 4, 118±123 ß 2001 Nature Publishing Group All rights reserved 1365±7852/01 $15.00 www.nature.com/pcan A population-based study on radical prostatectomy in France M SoulieÂ1,3*, A Villers1, P Grosclaude2,3,FMeÂnegoz2, P Schaffer2, J Mace-Lesec'h2, M Sauvage-Machelard2 & A Grand3 1Comite de CanceÂrologie de l'Association FrancËaise d'Urologie, France; 2ReÂseau FrancËais des Registres de Cancer, France; and 3INSERM U518, FaculteÂdeMeÂdecine, Toulouse, France There has as yet been no descriptive study of the practice of radical prostatec- tomy in the general population in France. The objective of this work was to investigate the use of radical prostatectomy (RP) in France and its determinants and geographic variations. A total of 175 radical prostatectomies was identi®ed in a random sample of 798 cases of prostate cancer recorded in 1995 by four cancer registries, in the departments of Bas-Rhin, Calvados, IseÁre and Tarn. Tumour characteristics, diagnostic procedures and histopathological results were ana- lysed. Multivariate analysis by logistic regression was used to take into account age, prostate speci®c antigen (PSA) levels and clinical stage in order to study variations between geographical departments and sectors of activity (private or public). The mean age of the patients at the time of diagnosis was 65.3 y (range 46 ± 76). Median PSA level was 18.2 ng/ml (range 1 ± 184). Diagnosis was made by randomised biopsies in 73.8% of cases or by transurethral resection (6.9%). Clinical stage was classi®ed T1 (22.3%), T2 (64%), T3 (8.6%), N (0.6%) and unknown (4.5%). The histopathological result was pT2N0 in 46.3% of cases, pT3N0 in 40%, pT4N0 in 1.7%, pTxN in 8.6% and unknown in 3.4%. Adjuvant therapy (radiotherapy 13.7%, hormonal treatment 13.7% or both 3%) was admin- istered in 54 patients (31%). Logistic regression showed that the probability of undergoing RP was three times higher in one department than in the other departments, and was 2.6 times as high in the private sector. This study on the practice of RP is the ®rst performed in the general population in France. It shows that practice differs according to geographical region and sector of activity, indicating that schools of thought and medical culture vary within the same country. Prostate Cancer and Prostatic Diseases (2001) 4, 118±123. Keywords: prostate cancer; epidemiology; radical prostatectomy; population registry Introduction localised carcinomas and also because of improved sur- gical technique and decrease in postoperative sequels.2 The detection of early prostate cancer increased markedly Radical prostatectomy is regularly proposed as curative in the 1980s, resulting in a pronounced increase in radical treatment to patients with localised prostatic adenocarci- prostatectomy (RP) in the USA.1 In the general population noma, although it is advocated only if the patient has an in France, determinants of treatment choices in prostate estimated life expectancy of more than 10 y.3,4 cancer are unknown. This is also true of RP, whose On the initiative of the Comite de CanceÂrologie de frequency has markedly increased over the last 10 y l'Association FrancËaise d'Urologie (CCAFU) and the because routine Prostate speci®c antigen (PSA) measure- French network of Cancer Registries, a population- ment has led to increased frequency of diagnosis of based study was carried out to obtain information on practices regarding management of prostate cancer during the year 1995 in four French cancer registries. *Correspondence: M SoulieÂ, MD, Service de Chirurgie Urologique, One of the aims of this investigation was to provide CHU Rangueil, F-31403 Toulouse Cedex 4, France. E-mail: [email protected] clinicians and epidemiologists with a recent, unbiased Received 14 September 2000; revised 30 November 2000; evaluation of the practice of RP in France and to reveal accepted 30 November 2000 any disparities between regions and sectors of activity. Radical prostatectomy in France M Soulie et al 119 Table 1 Radical prostatectomy in France in 1995: age groups Patients and methods (n 175 patients) Data were obtained from a random sample of 798 cases of Age (y) n% prostate cancer recorded in 1995 by cancer registries in four French geographic departments: Bas-Rhin, Calvados, 55 10 5.7 IseÁre and Tarn. These four departments differed by their 60 20 11.4 65 34 19.4 geographical situation and by availability of health care 70 71 40.6 facilities. They are situated in distant regions of France 75 35 20 (NE, NW and SW) and represented 3 million inhabitants 80 5 2.9 (about 6% of the French population) with disparities in Total 175 100 urbanisation (Tarn and Calvados were more rural) and health care distribution (no university hospital in Tarn, Comprehensive Cancer Centres only in Calvados and between the age groups. Diagnosis was made on elevated Bas-Rhin). There was some discrepancy in urologist dis- PSA levels alone in 32% of cases (P 0.001). tribution, especially in the SW of France where the urologists of the private sector were more numerous than in NE and NW. Prostate speci®c antigen This study applied to patients treated by RP. Of the 180 Prostate speci®c antigen had been measured before diag- patients who received RP, only 175 patients operated on nosis in 96.6% of cases. In 44.6% of patients PSA levels no later than one year after diagnosis were analysed. were already under surveillance before diagnosis. Median They represented 21.9% of the initial population of 798 PSA was 18.2 ng/ml (range 1 ± 184 ng/ml) with a normal patients with prostate cancer. Of this total population, level of less than 4 ng/ml for the population as a whole. 73% were managed in the private sector and 27% in the PSA was less than 10 ng/ml in 35.4% of patients, less than public sector. 4 ng/ml in 5.7% and above 50 ng/ml in 4.6%. In 3.4% of Characteristics of patients and of tumours, diagnosis patients PSA measurement had been done but the results procedures, management and treatment according to were unknown (Table 2). sector of activity were collected from medical records by investigators from each registry, using a questionnaire prepared by the CCAFU. Various clinical indicators were Clinical staging noted: urinary symptoms, ®ndings of digital rectal exam- ination (DRE), pre-operative PSA levels, diagnostic Clinical stage was de®ned from the various clinical ®nd- procedure (biopsies or transurethral resection), patholo- ings and the evaluation of extent of disease. DRE had gical results of the samples. The clinical stage of the been performed in all cases but the ®ndings were tumours was reassessed by centralised analysis of all unknown in 3.4% The tumour was classi®ed as T1 in questionnaires according to the Tumour-Node-Metastasis 22.3% of cases, T2 in 64% and T3 in 8.6% (Table 3). Of the classi®cation in use at this period (TNM 1992). 39 stage T1 tumours, 27 were T1c,8T1b and 4 T1a. Clinical To identify determinants of the practice of RP, we used stages did not differ signi®cantly between the private and bivariate analysis (w2 test) to study the frequency of RP public sectors (P 0.74). according to selected factors. We used a logistic regression in multivariate analysis to take into account the associa- Table 2 PSA levels in 175 patients with prostate cancer tions between the various factors. Wald test was per- formed in order to test each variable modality. Results PSA (ng/ml) n% were expressed as an adjusted odds ratio (aOR) compar- 0 ± 4 10 5.7 ing the modalities of a variable with a reference modality. 4 ± 10 52 29.7 All analysis was done using Stata software.5 10 ± 20 68 38.9 20 ± 50 31 17.7 > 50 8 4.6 Unknown 6 3.4 Total 175 100 Results Age groups Table 3 Correlation of clinical and pathological stages in 175 The mean age at diagnosis of the 175 patients who had patients with prostate cancer had RP was 65.3 y (range 46 ± 76 y), whereas the mean age Pathological staging of the total population of 798 patients was 71.6 y (46 ± 94). Of these 175 patients, 77.1% were aged less than 70 y and Clinical staging pT2 pT3 pT4 pN Unknown Total % 20% were aged between 70 and 75 y. No patient had surgical treatment after the age of 76 y (Table 1). T1 25 10 1 1 2 39 22.3 T2 53 46 1 10 2 112 64.0 T3 Ð 10 1 3 1 15 8.6 N Ð Ð 1 Ð 1 0.6 Circumstances of diagnosis Unknown 3 4 Ð Ð 1 8 4.5 Total 81 70 3 15 6 175 At diagnosis 63% of patients presented symptoms, % 46.3 40.0 1.7 8.6 3.4 usually urinary (95% of cases). There was no difference Prostate Cancer and Prostatic Diseases Radical prostatectomy in France M Soulie et al 120 Diagnostic procedures for prostate cancer Radical prostatectomy Prostate biopsy (PB) was performed in 159 patients We included in our study all patients who had had RP, (90.9%), mainly in those aged less than 70 y (97%). The whether alone or in association with adjuvant therapy technique used was not always speci®ed but 78.3% of (radiotherapy and/or hormonal therapy) operated on patients had had at least randomised needle biopsies with no later than one year after diagnosis. In half of these transrectal ultrasonography. 175 cases, surgery was performed within 50 days of Tumoral diagnosis was established by transurethral diagnosis.
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