American trends in expectant management utilization for prostate cancer from 2000 to 2009

National trends in management of localized prostate cancer: A population based analysis 2004-2013

PURPOSE

Recent years have brought many changes in the management of localized prostate cancer as national screening guidelines have been updated and diagnostic practice patterns evolved. We sought to better understand how the changing landscape influenced treatment utilization in the United States.

METHODS

We used the SEER database in this retrospective analysis of patients with clinically localized prostate cancer between 2004 and 2013. We evaluated utilization of primary treatment modalities over time with descriptive and trend analyses, and examined treatment utilization by cancer risk group and age at diagnosis.

RESULTS

Of 398 074 patients in the analytic data set, 38% elected radiation therapy, 38% underwent radical prostatectomy, and 24% opted for expectant management. While in 2004 radiation treatment was almost twice as common as expectant management (42% vs 23%), by 2013 approximately equal percentages of patients were treated with each of the three modalities. Expectant management use increased over time, while the proportion of patients opting for surgery decreased remarkably with increasing age at diagnosis in intermediate- and higher-risk disease. Among radiotherapy options, brachytherapy was most common among lower-risk patients in 2004 but substantially decreased over time (P < 0.001).

CONCLUSIONS

Management of localized prostate cancer changed substantially over time in the United States. Utilization of expectant management has increased for men with low- and intermediate risk cancer. Among those who pursue curative therapy, younger men remain more likely to elect surgery whereas older men tend to choose radiotherapy. Further studies are needed to better characterize factors contributing to treatment selection.

Contemporary Management of Prostate Cancer Patients Suitable for Active Surveillance: A North American Population-based Study

BACKGROUND

Active surveillance (AS) is increasingly recognized as a recommended treatment option for prostate cancer (PCa) patients with clinically localized, low-risk disease; however, previous studies suggested that its utilization is uncommon in the United States.

OBJECTIVE

We evaluated the nationwide utilization rate of AS in the contemporary era.

DESIGN, SETTING, AND PARTICIPANTS

We relied on the 2010-2011 Surveillance Epidemiology and End Results (SEER) database using all 18 SEER-based registries. We identified 9049 patients that fulfilled the University of California, San Francisco AS criteria (prostate-specific antigen level <10ng/ml, clinical T stage ≤2a, Gleason score ≤6 [no pattern 4 or 5], and percentage of positive biopsy cores <33%).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression analysis tested the relationship between receiving local treatment and all available predictors.

RESULTS AND LIMITATIONS

Only 32% of AS candidates did not receive any active local treatment. This proportion varied widely among the SEER-based registries, ranging from 13% to 49% (p<0.001). In multivariable analyses, clinical stage T2a (odds ratio [OR]: 1.23; p=0.04) and percentage of positive cores (OR: 1.10 for each 2% increase; p<0.001) were associated with a higher probability of receiving local treatment. Conversely, older age (OR: 0.89 for each 2-yr increase; p<0.001), not being married (OR: 0.64; p<0.001), and uninsured status (OR: 0.55; p=0.008) were associated with a lower probability of receiving active local treatment. The study is limited by the fact that SEER does not distinguish among patients undergoing observation, AS, watchful waiting, or initial hormonal therapy.

CONCLUSIONS

In the United States, a considerable proportion of patients suitable for AS receive local treatment for PCa. Proportions differ significantly among SEER registries.

PATIENT SUMMARY

Having more extensive and palpable disease, having medical insurance, being married, and being younger are associated with an increased probability of receiving local treatment for low-risk prostate cancer.

A hospital-based study of initial observation for low-risk prostate cancer and its predictors in the United States

INTRODUCTION

Initial observation (IO) is a strategy to minimize prostate cancer overtreatment. We sought to evaluate contemporary trends in IO utilization for low-risk prostate cancer in the United States and to identify factors associated with its uptake.

METHODS

Using the National Cancer Database, we identified men with low-risk prostate cancer diagnosed between 2004 and 2011. IO utilization was plotted over time. Multivariate logistic regression was performed to determine the influence of diagnosis year and other factors on IO selection.

RESULTS

Of the 219 971 men with low-risk prostate cancer, 21 231 (9.7%) underwent IO. Beginning in 2008, IO use increased significantly with time (range: 7.5%-14.3%). Compared to 2004, patients diagnosed in 2011 had 2.5 times the odds of choosing IO (odds ratio [OR] 2.5, confidence interval [CI] 2.3-2.6, p < 0.01). Aside from diagnosis year, age, race, Charlson score, clinical T stage, and PSA level predicted IO use (p < 0.01). Other predictors of IO included hospital type, insurance provider, and household income. Specifically, comprehensive cancer centres, private insurance, and higher income predicted decreased IO usage (OR 0.5, CI 0.5-0.5, p < 0.01; OR 0.4, CI 0.4-0.4, p < 0.01; and OR 0.8, CI 0.8-0.9, p < 0.01, respectively). Less educated men were also less likely to undergo observation (OR 0.8, CI 0.8-0.9, p < 0.01). Treatment within the western United States was significantly, but weakly, associated with increased use of IO (p < 0.01).

CONCLUSIONS

In recent years, low-risk prostate cancer has been increasingly managed with IO, appropriately driven by patient and disease factors. Unexpectedly, observation usage also varies by race, hospital, insurance, income, and geography, suggesting that non-clinical factors may affect treatment selection.