How is surveillance used in younger men?

The use of active surveillance for prostate cancer is increasing among younger, privately insured men, according to findings of a study presented at the AUA annual meeting in San Francisco.

The research, however, raises concern about the quality of the care provided, said first author Simon P. Kim, MD, MPH.

Using a large commercial insurance database including privately insured patients and Medicare Advantage enrollees (Optum Labs), the study identified 27,812 men ages ≥40 years diagnosed with biopsy-confirmed incident prostate cancer from January 2008 to December 2016. Regression modeling to analyze age-based time trends in the annual rate of active surveillance showed increases in men aged <70 years, with the highest gains in the subgroups of men aged 40 to 49 years and 50 to 59 years.

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Data on receipt of follow-up procedures showed that nearly all men (90%) had a PSA test within 12 months after their cancer diagnosis. Only approximately one-third of patients, however, had undergone a repeat biopsy.

“Active surveillance has become an established management option for patients with low-risk prostate cancer and/or limited life expectancy. Previous studies evaluating its implementation used Medicare data, and so it is unclear how active surveillance is being used in younger men,” said Dr. Kim, associate professor of urology, Case Western Reserve University School of Medicine, Cleveland.

“Our research indicates that active surveillance is being promoted and disseminated in the younger, privately insured patient population. It seems, however, that increased attention is warranted to develop evidence-based active surveillance protocols to ensure safety for these patients. Ultimately, there is also a need for prospective studies to assess outcomes of active surveillance for younger patients.”

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Dr. Kim suggested that the absence of standardized guidelines for surveillance strategies may be contributing to the less-than-optimal performance of follow-up biopsies.

“Existing surveillance protocol recommendations are mixed, and the inability to look to a universally accepted guideline for follow-up with PSA testing and prostate biopsy may be part of the problem,” Dr. Kim told Urology Times.

Men included in the database were identified as having received active surveillance based on absence of any primary therapy within the 6 months after they were diagnosed with localized prostate cancer.

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For men ages 40 to 49 years, the rate of active surveillance approximately tripled between 2008 and 2016 from 95.24 per 1,000 patients to 312.50 per 1,000 patients. The active surveillance rate for the 50- to 59-year-old cohort rose approximately 2.5-fold between the first and last years of the study period, from 88.71 per 1,000 patients to 226.60 per 1,000 patients.

In 2008, annual rates of active surveillance in the 60- to 69-year-old subgroup (133.05 per 1,000 patients) and the ≥70-year-old subgroup (196 per 1,000 patients) were higher than in the younger cohorts. The next year, active surveillance utilization grew in the two older subgroups. Thereafter, the annual rate was stable in the oldest cohort and increased more incrementally among 60- to 69-year-old men.

The multivariable logistic regression analysis also investigated associations between other patient-related variables and receipt of active surveillance. Looking at race/ethnicity and using Caucasian men as the reference group, it found that the odds of receiving active surveillance were significantly greater among Asian-Americans and significantly lower among African-Americans. The odds of receiving active surveillance was also significantly greater among Medicare Advantage enrollees compared with men having commercial insurance. Receipt of active surveillance did not vary by geographic region, Charlson comorbidity score, or household income levels.

“The findings relating to race/ethnicity were interesting considering that access to care was not a factor in our privately insured population and that African-American men have an increased likelihood of having more aggressive disease,” Dr. Kim said.