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Low-risk prostate cancer has a favorable prognosis without treatment. Current guidelines recommend conservative management or deferring upfront treatment as the preferred approach, 1 but previous studies reported underutilization in the United States 2,3 compared with other countries. 4 Qualitative data suggest that financial incentives and medicolegal concerns are barriers to uptake by US physicians. 5 We examined utilization of conservative management in the US Department of Veterans Affairs (VA), an integrated health care system providing equal access for patients without financial incentives for physicians to provide high-volume care. Methods | The study was approved by the VA New York Harbor institutional review board with a waiver of informed consent. Using VA's Central Data Warehouse, we examined treatment patterns for veterans diagnosed with low-risk prostate cancer (prostatespecific antigen [PSA] <10 ng/mL, Gleason ≤6, and stage cT1/T2a) from January 2005 through November 2015. Our dependent variable was receipt of curative therapy within 1 year of diagnosis (including androgen deprivation monotherapy), determined by administrative codes. Linkage to Medicare was performed to identify tests or treatment performed outside the VA for men 65 years or older. Men with PSA less than 1 ng/mL during follow-up were also classified as likely having received curative treatment outside the VA. Untreated veterans were classified as receiving conservative management, subdivided into active surveillance (≥2 PSAs and 1 biopsy within 2 years after diagnosis) or watchful waiting. The final date of follow-up was November 16, 2017. We explored use of conservative management over time, stratified by age. The Cochran-Armitage test was used to examine trends over time, and logistic regression was used to identify the association between year of diagnosis and conservative management, adjusting for age, race, marital status, PSA, comorbidity, and region. Men without a PSA, biopsy, or treatment recorded within 2 years were excluded. Analysis was performed using SAS Enterprise Guide (SAS Institute), version 7.1, and tests were 2-sided at an α of .05.

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