Trends in Active Surveillance for Management of Low-Risk Prostate Cancer in the United States

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In an analysis reported in JAMA Network Open, Cooperberg et al found that the use of active surveillance (AS) for low-risk prostate cancer in U.S. patients has more than doubled in recent years but remains suboptimal and exhibits wide variations at the urology practice and individual practitioner levels.

The investigators stated, “AS is endorsed by clinical guidelines as the preferred management strategy for low-risk prostate cancer, but its use in contemporary clinical practice remains incompletely defined.”

Study Details

The retrospective analysis involved data from the prospectively maintained American Urological Association (AUA) Quality (AQUA) Registry, a large quality-reporting registry including data from 1,945 urology practitioners at 349 practices across 48 U.S. states and territories, comprising more than 8.5 million unique patients. The analysis cohort included a total of 20,809 patients with low-risk disease—defined as prostate-specific antigen (PSA) < 10 ng/mL, Gleason grade group 1, and clinical stage T1c or T2a—newly diagnosed between January 2014 and June 2021 with known primary treatment.

Key Findings

Among the 20,809 patients, the median age was 65 years (interquartile range = 59–70 years); and 0.1% were American Indian/Alaska Native, 0.7% Asian/Pacific Islander, 8.9% Black, 40.1% White, 0.8% of other race/ethnicity, and 49.3% were missing information on race/ethnicity.

Slight variation in the proportion of patents with low-risk disease was observed between 2014 and 2021, ranging from 17.4% and 19.3% per year, with no discernible time-related trend.

The rates of use of AS increased consistently from 26.5% in 2014 to 59.6% in 2021. During the study period, use of AS varied from 4.0% to 78.0% at the urology practice level and from 0% to 100% at the practitioner level. AS rates were similar among Black patients (39.4%) and White patients (39.8%) and higher among patients with other or missing race/ethnicity (46.4%).

On multivariable analysis, year of diagnosis was the variable most strongly associated with use of AS, with an odds ratio (OR) per year between 2014 and 2021 of 1.25 (95% confidence interval [CI] = 1.24–1.27). Compared with 2014, the OR for 2021 was 4.48 (95% CI = 4.31–4.65). ORs were significant for some age decades of diagnosis, with 0.71 (95% CI = 0.52–0.89) for patients in their 40s, 1.12 (95% CI = 1.03–1.20) for those in their 60s, and 1.24 (95% CI = 1.15–1.34) for those in their 70s. Black men had reduced likelihood of AS vs White men (OR = 0.87, 95% CI = 0.75–1.00). Higher PSA level at diagnosis was associated with reduced likelihood of AS (OR = 0.98, 95% CI = 0.96–0.99).

The investigators concluded: “This cohort study of AS rates in the AQUA Registry found that national, community-based rates of AS have increased but remain suboptimal, and wide variation persists across practices and practitioners. Continued progress on this critical quality indicator is essential to minimize overtreatment of low-risk prostate cancer and by extension to improve the benefit-to-harm ratio of national prostate cancer early detection efforts.”

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

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