In patients with low-risk prostate cancer, the use of an active surveillance approach is significantly impacted by geographic location, according to a study recently published in JAMA Network Open. In this interview with i3 Health, Samuel L. Washington III, MD, MAS, Assistant Professor of Urology at the University of California San Francisco and the study's lead author, discusses the significance of these results and suggests ways to reduce variation in the use of active surveillance, thereby optimizing the management of low-risk prostate cancer.
What prompted you to investigate regional variation in the use of active surveillance for low-risk prostate cancer?
Samuel L. Washington III, MD, MAS: Prior to starting this project, our research group brainstormed ways to examine how and where active surveillance uptake has changed the most. Active surveillance has been 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. Prior studies have shown changes in the use of active surveillance or conservative treatment over time, but they were largely limited to summary trends, specific geographic regions, or individual institutions. We saw the release of the Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database as an opportunity to take a deeper dive into this question with a validated measure of the intent to use active surveillance, which was a new addition to SEER databases.
Can you comment on the significance of your findings?
Dr. Washington: In the large national dataset, we found that the broader level of geographic variation was driven by significant county-level variation in the uptake of surveillance. While not surprising, the degree of county-level variation was profound. It's important to note that this finding of local, small-area variation is not unique to prostate cancer, but it highlights the need for further investigation. Our first step to achieving more uniform, equitable access to care is greater insight into the drivers of these small-area variations in care.
What are some of the factors contributing to regional variation in the use of active surveillance for low-risk prostate cancer?
Dr. Washington: In this study, we combined the SEER Prostate with Watchful Waiting database with the County Area Health Resource File to incorporate detailed county-level demographics and physician distribution data. We found that the patient's age at diagnosis and year of diagnosis were associated with the use of surveillance, and factors such as Hispanic ethnicity and Medicaid enrollment were associated with lower odds of surveillance. We also found that Black race, county-level socioeconomic factors (household income, educational level, and city type) and specialist densities were not associated with the use of active surveillance, a finding which differed from prior studies.
What strategies can be utilized to reduce variation in the use of active surveillance for low-risk prostate cancer?
Dr. Washington: Our clinical guidelines have increasingly endorsed active surveillance as a safe approach to managing low-risk disease, and numerous studies have shown an overall increase in its utilization over time. Yet, the factors limiting surveillance uptake vary across geographic regions and clinical practices. In order to reduce variation in surveillance for low-risk prostate cancer, there is a need for strategies that leverage an iterative process of providing access to granular data on local practice patterns, which are then fed back to individual practices.
An example of that is how the American Urological Association (AUA), through the national AUA Quality (AQUA) Registry, is actively feeding practice data back to urology practices to help drive positive change toward more uniform adoption of surveillance, as well as other priority areas for improvement in quality of care. Opportunities for practices to review their own data and understand local barriers to surveillance are integral in reducing variation in the use of active surveillance for low-risk prostate cancer.
About Dr. Washington
Samuel L. Washington III, MD, MAS, is an Assistant Professor of Urology at the University of California San Francisco (UCSF). He specializes in the treatment of patients with genitourinary malignancies, and his clinical interests include the use of minimally invasive robotic and laparoscopic surgical approaches. Dr. Washington is a member of the American Urological Association and the Society for Urologic Oncology. His research focuses on addressing racial, ethnic, and socioeconomic disparities in the diagnosis and management of patients with genitourinary malignancies, especially clinically localized prostate cancer.
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
Transcript edited for clarity. Any views expressed above the speaker's own and do not necessarily reflect those of i3 Health.