Living and dying with prostate cancer : Population-based register studies

Abstract: Tailored treatment with adequate timing is essential for the quality of prostate cancer care at all stages. Overtreatment should be avoided due to the side effects, but undertreatment may on the other hand lead to progression and death. This thesis aims to describe the patterns of use for non-curative treatments of prostate cancer, alongside the time trends of disease characteristics of men who die from prostate cancer. The work was based on the National Prostate Cancer Register of Sweden (NPCR).The first study included 45 147 men. The cumulative incidence of castration was 11.6% at ten years after diagnosis, while it was 10.8% for antiandrogen monotherapy. Estimated median durations of castration ranged from four years in the deferred treatment high-risk group to seventeen years in the prostatectomy low-risk group. The second study included 114 cases and 1140 controls. Four men out of ten received androgen deprivation therapy although they had prostate-specific antigen doubling time ≥12 months and biopsy Gleason score ≤7, which was defined as non-adherence to the guidelines of the European Association of Urology. Most of these men had low-risk features at diagnosis. The third study included 8326 men. During the last year before death from prostate cancer, use of opioids increased from 30% to 72%. Men without close relatives and older men had lower probability to receive opioids. The fourth study included 45 850 men. During the study period of 1992 to 2012, the time trend showed a stage shift towards lower risk group at diagnosis, longer disease duration, and higher age at death among men who died from prostate cancer.The first two studies indicate that overtreatment with androgen deprivation therapy is common after curative treatment, why interventions to improve adherence to guidelines are needed.  The third study indicates that men without close relatives and older men are disadvantaged with respect to treatment of cancer pain, why they need closer attention from health care providers. The findings in the fourth study may reflect the synergetic effects of prolonged lead time, increased life expectancy, and improvements in the management of prostate cancer during the last two decades.