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Low-Risk Prostate Cancer: Active Surveillance Use Varies by Region

According to a recent cohort study, the use of active surveillance for low-risk prostate cancer is impacted by geographic location, despite a lack of association with Black race, the area's density of specialty physician's, or socioeconomic factors.

"Active surveillance is now recognized as the preferred management option for most low-risk prostate cancers to minimize risks of overtreatment," write the investigators, led by first author Samuel L. Washington III, MD, MAS, an Assistant Professor of Urology at the University of California, San Francisco. "Despite increasing use of active surveillance in the United States, wide regional variability has been observed, and these regional variations in contemporary practice have not been well described."

Using data from the Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database and the US Department of Health and Human Services County Area Health Resource File (AHRF), Dr. Washington and colleagues investigated the impact of geographic location on the use of active surveillance in 79,825 patients with clinically localized low-risk prostate cancer. The median age was 62.8 years, and 14.1% of patients were non-Hispanic Black. Factors that were evaluated included age, year of diagnosis, and county-level densities of urologists, radiation oncologists, and primary care physicians. The primary end point was the use of active surveillance or watch-or-wait as the initial reported treatment strategy.

Geographic location was significantly associated with the use of active surveillance, with the mean annualized percent increase between 2010 and 2015 ranging from 6.3% in New Mexico to 81.0% in New Jersey. Regional differences were responsible for 17% of the total variation in active surveillance usage. A greater likelihood of receiving active surveillance was seen in patients who were 51–60 years old (odds ratio, 1.33), 61–70 years old (odds ratio, 1.86), and 71–80 years old (odds ratio, 2.26). Lower rates of active surveillance were seen in Hispanic patients (odds ratio, 0.79), those with a more advanced tumor category (odds ratio, 0.79), and those receiving Medicaid (odds ratio, 0.73). Black race, the area's density of specialist physicians, and county-level socioeconomic factors including household income, educational level, and city type were not associated with the use of active surveillance.

"Use of active surveillance or watch-and-wait 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," conclude Dr. Washington and colleagues in their publication in JAMA Network Open. "Future policy efforts should aim to both continue the overall increase in active surveillance and watch-and-wait use across the country and reduce variation influenced by nonclinical factors."

For More Information

Washington SL, Jeong CW, Lonergan PE, et al (2020). Regional variation in active surveillance for low-risk prostate cancer in the US. JAMA Netw Open, 3(12):e2031349. DOI:10.1001/jamanetworkopen.2020.31349

Image credit: National Human Genome Research Institute. Licensed under CC BY 2.0

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