Significant variation in application of active surveillance

According to an article in the journal Cancer, men with low-risk prostate cancer diagnosed and managed at high-volume hospitals are 3.6 times more likely to be managed on active surveillance than those managed at low-volume institutions.

The article by Löppenburg et al. (see also this report in Cancer Therapy Advisor) is based on a retrospective analysis of data from > 115,000 men with low-risk prostate cancer diagnosed and initially managed at US hospital-based institutions between 2010 and 2014.

Over that time period, within this particular cohort of men, Löppenburg et al. report that:

  • The application of active surveillance as a first-line management strategy in low-rsik patieents increased from 6.8 percent in 2010 to 19.9 percent in 2014.
  • There was great inter-institutional variability in the probability of initial management with active surveillance.
  • As compared to patients treated at comprehensive community cancer centers,
    • Men treated at community cancer programs were twice as likely to receive initial management of active surveillance (odds ratio [OR] – 2.00).
    • Men treated at academic institutions were ~ 2.5 times as likely to receive initial management on active surveillance (OR = 2.47).
  • Men  treated at high-volume facilities were much more likely to receive initial management on active surveillance (OR = 3.57).
  • Patient and hospital characteristics accounted for 60.2 percent of the overall variation.
  • The treating institution accounted for 91.5 percent of the unexplained variability.

Among their conclusions, the authors state that development and implementation of

Policies to achieve consistent and higher rates of active surveillance, when appropriate, should be a priority of professional societies and patient advocacy groups.

Your sitemaster is in complete agreement with that conclusion and would note that the recent AUA/ASTRO/SUO guidelines on the management of localized prostate cancer are forthright about active surveillance as an appropriate and recommended management strategy for men with low-risk and very low-risk prostate cancer:

  • Guideline statement 7

Clinicians should recommend active surveillance as the best available care option for very low-risk localized prostate cancer patients. (Strong Recommendation; Evidence Level: Grade A)

  • Guideline statement 8

Clinicians should recommend active surveillance as the preferable care option for most low-risk localized prostate cancer patients. (Moderate Recommendation; Evidence Level: Grade B)

2 Responses

  1. Our Us Too chapter has provided information favorable to active surveillance for appropriate patients since 2005, with fresh information almost every year. The information is now strongly favorable to active surveillance, but the quoted guidelines will be a welcome addition. Thank you!

    We have seen increasing interest in this option in recent years at our group.

  2. During the drafting of the AUA/ASTRO/SUO guideline panel sessions we discussed the fact that many things differed in rural areas versus large institutions and cancer centers. Patients are more subjected to outside standards based upon various factors. Many physicians are practicing “what they know” but not what has changed in time is one reason. Lack of state of the art equipment is another.

    All panelists felt that active surveillance was one where it is not excusable to still be using the pre-USPSTF standard of diagnose and treat all but the very sick. But it’s still happening. We had heavy evidence on very low-risk that the appropriate first step was active surveillance (Grade A, Evidence Level: Strong). Same for low-risk but there was still some apprehensions on the data (Grade B, Evidence Level Moderate). There is careful word-smithing between statement 7 “best available care option” versus “preferable care option” in statement 8. I can say that when the draft went though the peer review phase prior to the release of the guideline, this was one area that there was consensus with these statements.

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