Slow but increasing uptake of observation in initial management of low-risk patients

A new article by Maurice et al. in the Canadian Urological Association Journal provides detailed information about the use of initial observation as a management strategy for low-risk prostate cancer between 2004 and 2011.

“Initial observation” as a management strategy for low-risk forms of prostate cancer encompasses both active surveillance and watchful waiting (depending on the precise situations of individual patients). The defining criterion is the avoidance of any form of early interventional therapy until such therapy actually becomes necessary.

Maurice et al. used data from the National Cancer Database to identify 219,971 men, all diagnosed with low-risk prostate cancer between 2004 and 2011. Analysis of the data available about these patients allowed the authors to demonstrate the following:

  • In total, 21,231/219,917 patients (9.7 percent) with low-risk disease were initially managed with observation only.
  • Low-risk prostate cancer patients tended to be
    • Better educated, wealthier, insured, Caucasian men living in metropolitan areas
    • Seeking care at major academic and comprehensive cancer centers
    • Relatively healthy and younger than age 70
    •  Diagnosed with clinical stage T1c prostate cancer and a PSA level > 4 ng/ml
  • Initial use of observation among low-risk patients increased significantly with time.
    • From 2004 to 2007, use of initial observation was relatively stable (range, 7.2 to 7.5 percent).
    • Between 2008 and 2011, use of initial observation rose steadily, peaking at 14.3 percent in 2011.
  • Compared to 2004, patients diagnosed in 2011 were 2.5 times more likely to elect initial observation as a management strategy (odds ratio [OR] = 2.5).
  • Age was the single greatest predictor for use of initial observation.
  • Compared to patients < 50 years of age,
    • Men > 70 years of age were 2.5 times more likely to receive initial observation (OR = 2.5).
    • Men > 80 years of age were 7.2 times more likely to receive initial observation (OR = 7.2).
  • Race, number of comorbitidies (Charlson score), clinical T stage, and PSA level were other clinical predictors for use of initial observation.
  • Non-clinical predictors of use of initial observation included hospital type, insurance provider, and household income.
  • Less educated men were also less likely to undergo observation.
This rise in the use of initial observation as a management strategy may be related to two factors:
  • Increased acceptance of active surveillance as a management strategy for low-risk disease (because it was first included in clinical practice guidelines as an alternative to active treatment in 2007)
  • Greater comfort among physicians in initiating active surveillance (and watchful waiting too) in men with limited life expectancies (i.e., age > 70 years and a Charlson score of ≥ 2)

It is worth noting, however, that during the same time frame (i.e., 2007 to 2011) the rates for initial use of observation as a management strategy for low-risk disease in Sweden were more like 41 to 59 percent, very close to the estimate of 38 to 60 percent of patients diagnosed with early prostate cancer and considered to be low risk based on the D’Amico criteria. Of course the differences in rates of initiation of observation as a first-line management strategy in Scandinavia and in the USA are highly likely to reflect cultural and financial disparities in practice patterns.

The authors note the following in their discussion of their findings:

There are significant barriers to widespread … adoption [of active surveillance] in the United States. While patient anxieties may limit utilization, physician influence is the single most important factor influencing the decision to undergo [active surveillance].

They also point out that, despite the increase in use of initial observation as a management strategy from 2008 to 2011, initial observation

is still under-utilized, possibly due to the influence of non-clinical factors. The future of [active surveillance] and, for that matter, of prostate cancer diagnosis depends on the continued adoption of [initial observation] by urologists.

2 Responses

  1. What is a Charlson score comprised of?

  2. The Charlson Comorbidity Index (CCI) or Charlson score is a tool that can be used to predict the 10-year mortality of a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer. Scores are assigned to a patient based on a range of factors that include his age and as many as 22 clinical conditions. For more information see the entry on Comorbidity on the Wikipedia web site or this more detailed explanation (which is really intended for clinicians and researchers).

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