Rates of active surveillance for low-risk prostate cancer rise, ‘remain suboptimal’
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Despite an increase in national, community-based rates of active surveillance for management of low-risk prostate cancer, the guideline-endorsed strategy remains underutilized, according to research published in JAMA Network Open.
Researchers reported persistent variation in use across practices and among practitioners.
“Although academic series have demonstrated the safety and appropriateness of active surveillance for many years, its adoption in community practice in the U.S., for a variety of reasons, has been slow,” Matthew R. Cooperberg, MD, MPH, a urologic cancer surgeon at UCSF Helen Diller Family Comprehensive Cancer Center, and colleagues wrote. “Until 2010, the proportion of low-risk disease managed with active surveillance in community practice was consistently less than 10%; during the past decade, this proportion has improved but remained less than 50%. The optimal rate of active surveillance has not been defined, but it is likely greater than 80%.”
Background and methodology
All major clinical guidelines now endorse active surveillance as the preferred management strategy for low-risk prostate cancer; however, rates have been historically low outside of academic urology settings until recent years.
Researchers conducted a retrospective analysis of a prospective cohort study to identify trends and variations among practices and practitioners in active surveillance use for men with low-risk prostate cancer.
The study included 20,809 men in the American Urological Association Quality (AQUA) Registry with low-risk prostate cancer (PSA less than 10 ng/mL, Gleason grade group 1 and clinical stage T1c or T2a) newly diagnosed between 2014 and June 1, 2021. The men had a median age at diagnosis of 65 years (interquartile range, 59-70); 40.1% identified as white, 8.9% as Black, 0.7% as Asian or Pacific Islander and 0.1% as American Indian or Alaska Native. The remainder had no available race or ethnicity information.
Researchers used data collected automatically from electronic health record systems at 345 participating practices. Use of active surveillance as primary treatment served as the outcome of interest.
Results
Rates of active surveillance increased from 26.5% in 2014 to 59.6% in 2021 among practices with 50 or more low-risk patients. Use varied widely at both the urology practice level, from 4% to 78%, and at the practitioner level, from 0% to 100%.
Multivariable analysis showed year of diagnosis as the variable most strongly associated with active surveillance, with age, race and PSA value also associated with odds of surveillance.
Next steps
Improvement in the practice patterns is crucial to improve outcomes for men with prostate cancer, according to the researchers.
“This cohort study found that national, community-based rates of active surveillance have increased but remain suboptimal, with wide variation across practices and practitioners,” researchers wrote. “The AQUA Registry has defined the use of [active surveillance] for low-risk disease as a critical quality indicator for urology. We hope over time to document further reductions in overtreatment rates, in turn improving the benefit-to-harm ratio for early detection and risk-adapted management of prostate cancer.”
Perspective
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Robert Abouassaly, MD, MS
The introduction of prostate cancer screening in the 1990s led to a dramatic increase in the diagnosis of prostate cancer. A significant portion of these cases are low-risk, clinically insignificant prostate cancer. Over the past 2 decades, there has been an increasing acceptance of active surveillance as a management strategy for these patients. The concept of surveilling cancer required a significant change in thinking for both providers and patients. However, with an increasing understanding of the low malignant potential of these tumors, as well as mounting evidence supporting the safety of this approach, increasing adoption of active surveillance has been observed.
The paper by Cooperberg and colleagues demonstrated a near doubling of active surveillance utilization for patients with low-risk prostate cancer over an 8-year period ending in 2021, per data from the American Urological Association Quality (AQUA) Registry. These findings are very encouraging and should be viewed as a success in the translation of the increasing understanding of the disease to a significant change in clinical practice.
Although the authors point out that active surveillance utilization remains suboptimal, the definition of optimal active surveillance utilization is not clearly defined. Often this is determined by disease factors alone, without taking into account patient preference, quality of life, cost and anxiety. Further, determination of candidacy for active surveillance relies on adequate disease risk stratification.
Unfortunately, the AQUA registry does not include data on all factors used in the determination of candidacy for active surveillance in contemporary urology practice, such as number of cores positive, prostate MRI findings or data from genomic testing. Also, the methodology used to determine active surveillance was “natural language processing of medical records,” and billing codes may not accurately capture when true active surveillance is being utilized. Both of these facts limit the ability to draw firm conclusions on whether the utilization of active surveillance is considered optimal.
What is more concerning, however, is the wide variability in active surveillance utilization noted between providers. Although some of this may be explained by differences in patient populations served (eg, differing disease characteristics, patient values, etc.), it also suggests that provider factors likely are influencing treatment decisions more than they should. As a society, urologists need to strive to ensure treatment intensity reflects malignant potential of the disease. It also is incumbent on the provider to take the time to describe the rationale for active surveillance, allowing them to realize that the balance of risk to benefits clearly supports the use of this approach for these patients.
Taking the best interest of the patients into account when making decisions undoubtedly will lead to optimal utilization of active surveillance for patients with low-risk prostate cancer.
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