The uptake of active surveillance for the management of prostate cancer: A population-based analysis

Abstract

Introduction: Active surveillance (AS) is a strategy for the management of low-risk prostate cancer (PCa). However, few studies have assessed the uptake of AS at a population level and none of these were based on a Canadian population. Therefore, our objectives were to estimate the proportion of men being managed by AS in Ontario and to assess the factors associated with its uptake. Methods: This was a retrospective, population-based study using administrative databases from the province of Ontario to identify men ≤75 years diagnosed with localized PCa between 2002 and 2010. Descriptive statistics were used to estimate the proportion of men managed by AS, whereas mixed models were used to assess the factors associated with the uptake of AS. Results: 45 691 men met our inclusion criteria. Of these, 18% were managed by AS. Over time, the rates of AS increased significantly from 11% to 21% (p<0.001). Older age, residing in an urban centre, being diagnosed in the later years of the study period, having a neighborhood income in the highest quintile, and being managed by urologists were all associated with greater odds of receiving AS. Conclusions: There has been a steady increase in the uptake of AS between 2002 and 2010. However, only 18% of men diagnosed with localized PCa were managed by AS during the study period. The decisions to adopt AS were influenced by several individual and physician characteristics. The data suggest that there is significant opportunity for more widespread adoption of AS. IntroductionSince the introduction of prostate-specific antigen (PSA)-based screening, there has been an increase in the incidence of prostate cancer (PCa).1,2 However, this increase is mostly driven by an increase in the diagnosis of clinically insignificant cancers.3 Thus, the management of PCa has been associated with considerable overtreatment. Active surveillance (AS) has been proposed as a strategy to decrease overtreatment [4][5][6][7][8][9][10] and is now recognized as a management option by a number of evidence-based guidelines. 11-13Although several prospective series have reported on its safety, 4-10 few studies have reported on the uptake of AS at a population level. [14][15][16][17][18][19][20][21][22][23] No previous population-based study has evaluated the proportion of men being managed by AS in Canada. In other areas of PCa management, there are significant differences between Canada and other countries. Although a recent single-institution series from the University of Ottawa has examined the treatment patterns of men diagnosed with low-risk PCa, 24 there remains a need to better understand the rates of AS use and the factors related to its adoption, outside of single-institution series. We hypothesized that the rates of AS increased throughout the study period. Methods ParticipantsThis was an institutional review board-approved, population-based, retrospective study that identified, using administrative databases, men aged 18-75 years who were diagnosed with adenocarcinoma of the prostate betwe...

The Efficacy and Safety of Conventional and Hypofractionated High-Dose Radiation Therapy for Prostate Cancer in an Elderly Population: A Subgroup Analysis of the CHHiP Trial

“…Equivalent results were seen in the 75+ group to ≤75 group despite less favourable features at presentation. This imbalance of prognostic factors between age groups may relate to clinician or patient preference for an active surveillance strategy with increasing age as observed previously In a Canadian population-based study (16). We are not aware of any previous evidence of a relatively beneficial effect of hypofractionated RT in older patients with PCa.…”

Factors Associated with Discontinuation of Active Surveillance among Men with Low-Risk Prostate Cancer: A Population-Based Study

“…Population-based studies prior to 2010 from the United States, Sweden and Canada have reported low (15%e18%) uptake of AS in eligible low-risk patients. 3,9,10 AS uptake varied from 32% to 58% between 2011e2014 in the United States 11e13 and was up to 91% in very low-risk and 74% in low-risk PC between 2011e2014 in Sweden. 14 Published studies using multi-institutional data between 2010 and 2012 demonstrated that there was a 13%e17% discontinuation of AS at 1 year, 15,16 and population-based data from Sweden found that 36% of men discontinue by 5 years.…”

Detection rate for significant cancer at confirmatory biopsy in men enrolled in Active Surveillance protocol: 20 cores vs 30 cores vs MRI/TRUS fusion prostate biopsy

“…Active surveillance (AS) has become an alternative (1)(2)(3) to definitive treatment of low/very low risk prostate cancer (PCa), focusing on prevention of overtreatment (1) and strict monitoring over time of patients to establish potential risk reclassification. However, follow-up in the majority of AS protocols is still short, and prospective validation of criteria for selecting low-risk disease is still lack-weighted (T2W), axial diffusion weighted imaging (DWI), axial dynamic contrast enhanced (DCE) and spectroscopy were performed for each patient.…”