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Prostate Cancer

Same stage, same risk, different treatment: where a Korean man lives predicts what is done about his prostate cancer

Capital and urban residence meant more surgery for localised disease and more intensified systemic therapy for metastatic disease. Non-capital and rural residence meant hormone therapy alone — and the association survived adjustment for age, PSA, grade and stage.

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In short

In a nationwide stage- and risk-stratified analysis of 27,075 Korean men with prostate cancer treated between 2010 and 2020 across 51 general hospitals, with initial management classified into ten mutually exclusive categories and risk assigned by NCCN version 2.2024 criteria applied uniformly across survey years, capital and urban residence were associated with greater use of surgery in localised disease and greater systemic intensification in metastatic disease while non-capital and rural residence relied more on androgen deprivation therapy alone (all p < 0.001) — and residential context remained independently associated with treatment selection in multivariable analysis after adjustment for age, prostate-specific antigen, grade and stage.

Key takeaways

  • 27,075 Korean men treated for prostate cancer from 2010 to 2020 across 51 general hospitals were analysed.
  • Initial treatment was classified into ten mutually exclusive categories, from active surveillance through to androgen receptor-targeted agents after androgen deprivation therapy.
  • In localised disease, surgery predominated, active surveillance was most frequent in low-risk disease, and radiotherapy and hormone therapy alone rose with increasing risk (p < 0.001).
  • Capital and urban residence were associated with more surgery in localised disease and more systemic intensification in metastatic disease (all p < 0.001).
  • Non-capital and rural residence relied more on androgen deprivation therapy alone.
  • Residential context remained independently associated with treatment selection after adjustment for age, PSA, grade and stage.
  • Over the decade, hormone therapy alone declined in metastatic disease while radiotherapy and systemic intensification rose (p = 0.004).

A finding that rural patients get different cancer treatment is usually explained away in one step: they present later, with worse disease, so of course the treatment differs. This analysis removes that explanation by stratifying on stage and risk first, and the geography is still there afterwards.

What was held constant

Initial management was sorted into ten mutually exclusive categories rather than the usual two or three, which is what makes the comparison legible — surgery and surgery after androgen deprivation therapy are different decisions, and so are radiotherapy, radiotherapy after hormone therapy, docetaxel after hormone therapy, an androgen receptor-targeted agent after hormone therapy, and hormone therapy alone for a year or more. Risk was assigned using NCCN version 2.2024 criteria applied uniformly across all six survey years, so a 2010 patient and a 2020 patient are graded by the same ruler.

Within localised disease the pattern is the expected one and it is reassuring: surgery predominated, active surveillance was most common in low-risk disease, and radiotherapy and hormone therapy alone became more frequent as risk rose. Korean practice, in aggregate, follows the guidelines.

Where it stops following them

independent

residential context remained associated with treatment selection after adjusting for age, PSA, grade and stageKo YH et al., Investigative and Clinical Urology, 2026

That single word is the finding. Adjustment for age, PSA, grade and stage is adjustment for the clinical facts that are supposed to determine treatment. Once they are accounted for, two men with the same disease are still managed differently depending on whether they live in the capital region.

The direction is consistent at both ends of the disease. In localised cancer, capital and urban residence meant more surgery. In metastatic cancer, it meant more systemic intensification — adding a second agent to hormone therapy rather than leaving hormone therapy to run alone. Non-capital and rural residence meant androgen deprivation therapy on its own in both settings.

The decade did move

Hormone therapy alone declined in metastatic disease over the period while radiotherapy and systemic intensification rose (p = 0.004), which tracks the international shift in metastatic prostate cancer treatment during those years. Korean practice adopted it. The question this study raises is whether it adopted it everywhere at the same rate, and the answer, across stage and risk, is no.

Sources

  1. 1

    Ko YH, Kim SW, Son NH

    Residential location shapes initial prostate cancer care in Korea (2010-2020): A nationwide stage- and risk-stratified study

    Investigative and Clinical Urology 2026;67(5):468-477

    doi:10.4111/icu.20260160 · PMID:42683859

    https://doi.org/10.4111/icu.20260160