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Variation in Active Surveillance for Low-Risk Prostate Cancer in the United States


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In a cohort study reported in JAMA Network Open, Washington et al found that the use of active surveillance or watchful waiting for patients with low-risk prostate cancer in the United States varied by region, but not according to factors such as Black race or county-level socioeconomic status.

As stated by the investigators, “Active surveillance is now recognized as the preferred management option for most low-risk prostate cancers to minimize risks of overtreatment. Despite increasing use of active surveillance in the U.S., wide regional variability has been observed, and these regional variations in contemporary practice have not been well described.”

“In this U.S. cohort study based on the SEER-Watchful Waiting database, although the use of active surveillance increased, considerable practice variation appeared to be associated with geographic location, but use of active surveillance was not associated with Black race, specialty professional density, or socioeconomic factors.”
— Washington et al

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Study Details

The study used data from the Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database linked to the County Area Health Resource File for detailed county-level demographics and physician distribution data from January 2010 to December 2015. Odds ratios for use of active surveillance/watchful waiting are from a multilevel mixed effect logistic regression model including SEER region, patient factors, and county-level factors.

Key Findings

A total of 79,825 men with clinically localized low-risk prostate cancer eligible for active surveillance or watchful waiting (14.1% Black, 9.4% Hispanic) were included in the analysis.

Overall, the proportion of men who received active surveillance or watchful waiting increased from 13.1% in 2010 to 32.5% in 2015. The mean annualized percent increase in active surveillance rates ranged from 6.3% in New Mexico to 81.0% in New Jersey.

Overall use of active surveillance/watchful waiting was 22.1%. According to SEER registry region, the highest rates were in San Francisco-Oakland (42.4%) and San Jose-Monterey (33.9%)—both in California—and the lowest were in rural Georgia (4.1%) and New Mexico (9.3%). Differences across SEER regions accounted for 17% of the total variation in use of active surveillance/watchful waiting in the cohort.

Increasing age (51–60 years: odds ratio [OR] vs ≤ 50 years = 1.33, 95% confidence interval [CI] = 1.21–1.46; 61–70 years: OR = 1.86, 95% CI = 1.70–2.04; 71–80 years: OR = 2.26, 95% CI = 2.05–2.50) was associated with increased likelihood of active surveillance/watchful waiting. Lower likelihood of active surveillance/watchful waiting use was found for Hispanic patients (OR vs White patients = 0.79, 95% CI, 0.74–0.85) but not Black patients (OR vs White patients = 1.01, 95% CI = 0.95–1.07). Lower likelihood of active surveillance/watchful waiting use was also seen according to T category (T2a vs T1c: OR = 0.79, 95% CI = 0.73–0.84), and Medicaid enrollment vs private or Medicare insurance (OR = 0.73, 95% CI = 0.66–0.81).

County-level socioeconomic factors—including household income, educational level, and city type—and medical specialist densities were not significantly associated with the use of active surveillance/watchful waiting.

The investigators concluded: “In this U.S. cohort study based on the SEER-Watchful Waiting database, although the use of active surveillance increased, considerable practice variation appeared to be associated with geographic location, but use of active surveillance was not associated with Black race, specialty professional density, or socioeconomic factors. This small area variation underlies the broader national trends in active surveillance practice and may inform policies aimed at continuing to affect risk-appropriate care for men throughout the U.S.”

Matthew R. Cooperberg, MD, MPH, of the Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, is the corresponding author for the JAMA Network Open article.

Disclosure: For full disclosures of the study authors, visit jamanetwork.com.


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