Rates of active surveillance for low-risk prostate cancer have improved nationally but vary locally and remain subpar overall, according to findings from a study published in JAMA Network Open.
Although rates of active surveillance (AS) for prostate cancer are rising nationally, they vary locally and remain subpar overall, according to findings from a study published in JAMA Network Open. Considering clinical guidelines recommend AS for the management of low-risk prostate cancer, improving the practice patterns seen in the study is crucial.
Although prostate cancer is the second most deadly type of cancer in US men, most cases identified via screening are indolent, the study authors noted. Historically, prostate cancers would be treated regardless of risk, but significant morbidity and costs can be associated with overtreatment of low-risk prostate cancers.
“Prostate-specific antigen–based prostate cancer early detection efforts that aim to identify high-risk, potentially lethal cancers still in the window of opportunity for cure have helped decrease age-adjusted mortality rates by nearly half since the 1990s,” the authors wrote. “However, the principal downside screening is overdiagnosis and subsequent overtreatment of low-risk disease, the latter associated with long-term potential adverse effects.”
AS intends to minimize potential adverse events and entails monitoring low-risk patients through periodic prostate-specific antigen (PSA) testing, imaging, and biopsies until progressive disease is identified. If the disease progresses, treatment with curative intent can be initiated at the practitioner’s discretion. All major clinical guidelines recommend AS for the management of low-risk prostate cancer, the study authors noted.
The study analyzed trends, associations, and variations in AS implementation among a cohort of more than 20,000 men low-risk prostate cancer identified in the American Urological Association (AUA) Quality (AQUA) Registry. The registry automatically collects data from electronic health record systems at urology practices and included data from more than 8.5 million unique patients treated by 1945 practitioners at 349 practices across the United States at the time of the study.
The main outcome was the use of AS for primary treatment as determined by electronic health records for each patient. This included structured and unstructured clinical data in electronic health records, and surveillance was determined by follow-up testing with at least 1 PSA level higher than 1 ng/mL.
A total of 20,809 patients with newly diagnosed, low-risk prostate cancer between January 2014 and June 2021 who had known primary treatment were included in the study cohort, with low-risk disease defined as PSA levels less than 10 ng/mL, Gleason grade group 1, and clinical stage T1c or T2a. The median (IQR) age at diagnosis was 65 (59-70) years.
From 2014 to 2021, overall rates of AS in the study cohort more than doubled, consistently increasing from 26.5% at the beginning of the study period to 59.6% in 2021. But at the practice level, AS implementation varied from 4% to 78%. At the practitioner level, the use of AS varied from 0% to 100%.
Based on a multivariable analysis, the variable that impacted AS rates the most was year of diagnosis. The odds ratio (OR) for each individual year was progressively higher, with patients diagnosed in 2021 more than 4 times as likely to be managed with AS compared with patients diagnosed in 2014 (odds ratio [OR], 4.48; 95% CI, 4.31-4.65). Patients who were older and those with lower PSA levels at diagnosis were more likely to receive AS, and White patients were more likely to receive AS than Black patients.
While the findings show a growing proportion of patients receiving AS for low-risk prostate cancer, the rates are still not optimal. The ideal rate of AS is yet to be defined, but the US Veterans Affairs system and other health systems have estimated it to be greater than 80%, the study authors noted.
The study was limited by its reliance on electronic health record data, which are often incomplete. Race and ethnicity data, for example, are often missing and were not available in nearly 50% of the study cohort. Additionally, the AQUA data do not perfectly capture radiation therapy data or AS quality.
“This cohort study found that national, community-based rates of AS have increased but remain suboptimal, with wide variation across practices and practitioners,” the authors concluded. “The AQUA Registry has defined the use of AS for low-risk disease as a critical quality indicator for urology. We hope over time to document further reductions in overtreatment rates, in turn improving the benefit-to-harm ratio for early detection and risk-adapted management of prostate cancer.”
Cooperberg MR, Meeks W, Fang R, Gaylis FD, Catalona WJ, Makarov DV. Time trends and variation in the use of active surveillance for management of low-risk prostate cancer in the US. JAMA Netw Open. 2023;6(3):e231439. doi:10.1001/jamanetworkopen.2023.1439