Study: Active surveillance uptake remains low

The overall use of active surveillance in men with low-risk prostate cancer is 14.2%, according to an examination of the National Cancer Data Base.

Boston-The overall use of active surveillance (AS) in men with low-risk prostate cancer is 14.2%, according to an examination of the National Cancer Data Base.

In addition, variation in the use of AS is significant across facilities, reported Björn Löppenberg, MD, at the AUA annual meeting in Boston.

Dr. Loppenberg“Given current concerns for overdiagnosis and overtreatment of indolent prostate cancer, low rates and inconsistent use of active surveillance are alarming,” said Dr. Löppenberg, fellow in the division of urologic surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston.

Recent reports on the utilization of AS in the U.S. have shown encouraging results. The Michigan Urological Surgery Improvement Collaborative (MUSIC) of 17 Michigan-based practices reported that 48% of eligible patients received AS. Other collectives report utilization rates of AS in the range of 40%.

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“However, these reports are limited to certain geographical regions or certain patient collectives,” he said.

The Brigham and Women's Hospital group conducted a retrospective cohort study of 40,215 men with low-risk prostate cancer within the National Cancer Data Base, diagnosed in 2012 and 2013. Low risk was defined as cT1-cT2 disease with a serum PSA level <10.0 ng/mL and a Gleason score ≤6.

“Additionally, we wanted to assess the variation in care; therefore, we used a mixed-effects model to assess which factors contribute to variation,” said Dr. Löppenberg, who worked on the study with Quoc-Dien Trinh, MD, and colleagues.

Some 1,172 facilities were included in the analysis. Overall, 14.2% of eligible men received AS. The unadjusted rate in treatment variation ranged from 0 to 62% in facilities treating more than 75 patients within the study period.

Next: Facility volume, type linked with AS

Facility volume, type linked with AS

Factors associated with receipt of AS were facility volume and facility type. The odds ratio of receipt of AS was 3.5 (95% CI: 1.84-6.68; p<.001) in facilities with the highest volume compared with lowest volume. The highest likelihood of receipt of AS was in community cancer programs and academic institutions. Relative to patients treated at comprehensive community cancer centers, patients treated at community cancer programs had an OR of 2.74 (95% CI: 1.94-3.88; p<.001) and those treated at academic institutions had an OR of 2.50 (95% CI: 1.77-3.54; p<.001).

“There are some high-volume facilities that almost never treat patient with AS,” Dr. Löppenberg said.

Adjusted for all factors, the mean probability of receiving AS was 0.033 (95% CI: 0.023-0.256).

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The overall model explained 40% of the variation in receipt of AS. Of the unexplained variation, 35% could be attributed to a single facility, he said.

“Policies to achieve more consistent and higher rates of AS, when appropriate, should be a priority of professional societies and patient advocacy groups,” Dr. Löppenberg said.

The National Cancer Data Base captures about 70% of all newly diagnosed prostate cancer in the United States, he explained.

“The NCDB estimates that approximately 50% of all newly diagnosed prostate cancers are within their database,” he said. “So we think that quite a large proportion of these patients do not receive AS.”