US Active Surveillance Rates for Low-Risk Prostate Cancer Vary by Location

By Marilynn Larkin

January 08, 2021

NEW YORK (Reuters Health) - Active surveillance rates for low-risk prostate cancer vary by geographic location in the U.S. and may be linked to risk of overtreatment in some areas, researchers suggest.

"Active surveillance is increasingly recognized as the preferred standard of care for most men with low-risk prostate cancer, but how consistently it is offered across the country has not been clear," Dr. Matthew Cooperberg of the University of California, San Francisco told Reuters Health by email. "We found profound county-level variation in uptake of surveillance, which generally dwarfed variation at the broader level of geographic region. This finding of local, small-area variation is not surprising, and is hardly unique to prostate cancer."

"The first step to achieving more uniform, equitable access to care is identifying where specifically the problems lie," he said. "The American Urological Association, through the AUA Quality Registry, is actively feeding data like these back to urology practices to help drive positive change toward more uniform adoption of surveillance among other priority areas for quality-of-care improvement."

As reported in JAMA Network Open, Dr. Cooperberg and colleagues analyzed SEER Prostate with Watchful Waiting data from 2010-2015 on close to 80,000 men with localized, low-risk prostate cancer (mean age, 63; 66% non-Hispanic White; 14% non-Hispanic Black; 9% Hispanic). Active surveillance or watchful waiting was the first reported treatment strategy.

The mean annualized percent increase in active surveillance rates during the study period ranged from 6.3% in New Mexico to 81% in New Jersey. Differences across SEER regions accounted for 17% of the total variation in active surveillance.

Increasing age was associated with greater odds of active surveillance: 51-60, odds ratio, 1.33; 61-70, OR, 1.86; 71-80, OR, 2.26.

Lower odds of active surveillance were associated with Hispanic ethnicity (OR, 0.79); T category (OR, 0.79); and Medicaid enrollment (OR, 0.73).

By contrast, Black race, county-level socioeconomic factors (household income, educational level, and city type), and specialist densities were not associated with active surveillance.

Summing up, the authors state, "The rates of (active surveillance and watchful waiting) increased in the US through the first half of the 2010s, but in most regions remained below optimal levels. Use...varied substantially both across and within SEER regions, almost independent of patient- and county-level characteristics, such as socioeconomic factors or medical resources, reflecting local disparities in the awareness or acceptance of active surveillance."

Dr. Alexander Kutikov, Chief, Division of Urology and Urologic Oncology at Fox Chase Cancer Center in Philadelphia, told Reuters Health the question of what can be done about the variance is "challenging."

"Physician and patient education is key," he said. "Very low risks of active surveillance must be balanced against the deliverables of forgoing or delaying treatment. Since the field is largely in consensus that appropriate rates of active surveillance for low-risk disease is a quality-of-care metric, tracking and keeping physicians accountable for active surveillance adoption will be important. Some have proposed linking reimbursement to active surveillance utilization, but this approach is controversial and fraught with pitfalls."

"Clinicians should review rates of active surveillance in their practice and compare active surveillance utilization amongst providers," he said. "This is being done extremely effectively as part of state-wide quality collaboratives in some regions. Physicians who are outliers appear to rapidly adjust behavior after seeing that their practice patterns drastically differ from their peers."

SOURCE: JAMA Network Open, online December 28, 2020.