Whole-of-population based studies In urologic cancer

Abstract

Since Prostate Specific Antigen testing became commercially available prostate cancer has transformed from a clinically diagnosed often advanced disease usually in elderly men, to a biochemically detected usually organ confined condition which more often affects younger males. This resulted in a major shift in the patterns of care of prostate cancer from an observant, pharmaceutical therapy dominated algorithm, to surgically directed management via radical prostatectomy. This transition initially was undertaken on the basis of logic but with little conclusive evidence to support this change. It was this major adjustment in practice that was the impetus for this thesis. Few prospectively established whole-of–population registries of patients undergoing radical prostatectomy had been established at the time this project was conceived. The aim of this project was to follow sequentially for a 10 year period the progress of all men treated by radical prostatectomy in the state of Victoria, with a view to determining the likelihood of progression to objective biochemical and clinical benchmarks in the future. Multiple publications were derived from this registry, and from projects that have arisen as a consequence of the existence of the central database. Outcomes identified include the very low risk of prostate cancer specific mortality (PCSM) even after biochemical recurrence, especially in men with lower risk prostate cancer at diagnosis, and that predictors of PCSM independent of tumour stage and grade included rural residency of patients (p=.003), involvement of a trainee surgeon in the operation (p=.014), presentation with voiding symptoms rather than on the basis of an elevated PSA level, and the primary surgeon contributing less than 40 cases (low volume) to the VRPR (p=.024). As a consequence of the existence of our whole of population based registry of radical prostatectomy for prostate cancer the implications became apparent for patients of having a strong family history of breast cancer and of being a carrier of one or more variants of the BRCA gene. Extension of this concept resulted in a series of all men treated by High Intensity Focused Ultrasound (HIFU) upon its introduction in the state of Victoria, and a patterns of practice study of all patients in this state undergoing surgery for renal cell carcinoma.