Study Suggests Use of Active Surveillance for Prostate Cancer Is Increasing

The use of active surveillance for indolent prostate cancer cases continues to rise in the United States, but rates of use are lower in minority groups, low-income groups, and patients in rural areas, a recent study found.

For low- and some intermediate-risk prostate cancer cases, active surveillance (AS) has been increasingly recognized as the standard of care vs definitive treatment, and a research letter published in JAMA Internal Medicine suggests that the rate of AS use in the United States is increasing.1

For patients with low- or intermediate-risk prostate cancer that is progressing very slowly, AS is a management strategy that can help avoid potential quality-of-life impacts of radical treatment. Recent research suggests that patients with localized disease detected early by prostate-specific antigen (PSA) testing have similar prostate cancer–specific mortality outcomes whether they undergo active treatment or are managed with AS.2

The current study utilized data from the Surveillance, Epidemiology and End Results (SEER) Prostate with Watchful Waiting (WW) database from 2010 to 2018. The database includes men older than 40 years with low-risk and favorable intermediate-risk prostate cancer from 2010 to 2018. The SEER-WW database also includes information on whether patients were managed with AS or WW. While AS entails monitoring cancer for progression, WW only involves observing it until the patient experiences symptoms.

The Cochran-Armitage test (1-sided) was used to assess temporal trends and linear regression analysis was assessed with linear regressions analysis. The associations with AS or WW vs definitive treatment with patient demographics were assessed with multivariable logistic regression analysis.

Over time, the rate of AS/WW increased. In patients with low-risk disease, the AS/WW rate rose from 16.4% to 59.9%; and the rate increased from 7.8% to 21.8% in patients with favorable intermediate-risk cancers. The median (IQR) age of patients whose low-risk prostate cancer was managed with AS/WW decreased from 65 (60-71) years to 64 (59-69) years in the study period. Median (IQR) patient age for those with favorable intermediate-risk disease decreased from 70 (64-76) years to 67 (61-71) years.

The multivariable analyses showed that the use of AS/WW was associated with higher income, and Asian/Pacific Islander and Hispanic patients were less likely to be managed with AS/WW vs White men. The number of positive biopsy cores was linked to higher odds of definitive treatment, and patients in rural settings with low-risk prostate cancer were more likely to undergo definitive treatment.

“Interestingly, in low-risk disease, 2 positive cores were associated with an almost 50% decrease in AS use. Although AS series have shown an association between cancer volume on biopsy and clinical outcomes, it is unclear whether the presence of a second positive core should have such an impact on AS use,” the authors wrote. “This is worrisome, particularly with the increasing use of magnetic resonance imaging in biopsy, which may bias toward more positive cores and potentially higher rates of downgrading at prostatectomy.”

The study was limited in its inclusion of men with known treatment or surveillance rather than all prostate cancer patients, but still suggests the use of AS continues to rise in the United States. Still, uptake has been slower in minority groups, low-income groups, and patients in rural areas, demonstrating persistent disparities that must be addressed.


1. Al Hussein Al Awamlh B, Barocas DA, Zhu A, et al. Use of active surveillance vs definitive treatment among men with low- and favorable intermediate–risk prostate cancer in the US between 2010 and 2018. JAMA Intern Med. Published online April 3, 2023. doi:10.1001/jamainternmed.2022.7100

2. Hamdy FC, Donovan JL, Lane A, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. Published online March 11, 2023. doi:10.1056/NEJMoa2214122

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