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Conservative management becomes most common approach for low-risk prostate cancer

Conservative prostate cancer management with active surveillance or watchful waiting increased significantly between 2010 and 2015 among men with low- and intermediate-risk localized disease, according to results of a SEER analysis published in JAMA and scheduled for presentation at Genitourinary Cancers Symposium.

The threefold increase among low-risk men — from 14.5% in 2010 to 42.1% in 2015 — made it the most commonly used approach in that patient population.

“What we know from high-level evidence is that conservative management of low-risk prostate cancer is associated with a very favorable prognosis,” Brandon A. Mahal, MD, clinical fellow in radiation oncology at Dana-Farber/Brigham and Women’s Cancer Center, said in a press release. “Many men with low-risk disease are able to be spared the toxicity of treatment so it’s an important discussion to have between clinicians and patients.”

Mahal and colleagues reviewed the custom SEER Prostate Active Surveillance/Watchful Waiting database to identify 164,760 men (median age, 64 years; interquartile range, 59-70; 16.2% black) with localized prostate cancer diagnosed between 2010 and 2015 who had a known management strategy.

Among these men, 20,879 (12.7%) used active surveillance/watchful waiting; 68,350 (41.5%) received radiotherapy; and 75,531 (45.8%) underwent radical prostatectomy.

Compared with men diagnosed in 2010 (n = 31,355), men diagnosed in 2015 (n = 25,140) had significantly lower rates of low-risk disease (24.5% vs. 34.2%), older median age (65 years vs. 64 years) and higher median PSA concentration (6.7 ng/mL vs. 6 ng/mL; P = .05 for all).

Among men with low-risk disease (n = 50,302), the researchers observed an increase from 2010 to 2015 in use of active surveillance/watchful waiting (14.5% to 42.1%) and decreases in use of radical prostatectomy (47.4% to 31.3%) and radiotherapy (38% to 26.6%; P < .001 for trend for all).

Men with intermediate-risk disease (n = 81,836) also demonstrated an increase in active surveillance/watchful waiting (5.8% to 9.6%, P < .001 for trend) and decreases in radical prostatectomy (51.8% to 50.6%, P = .004 for trend) and radiotherapy (42.4% to 39.8%, P < .001 for trend).

The use of active surveillance/watchful waiting remained consistent among men with high-risk disease (n = 32,622; 1.9% to 2.2%), whereas radical prostatectomy use increased from 38% to 42.8% (P < .001 for trend) and radiotherapy use decreased from 60.1% to 55% (P < .001 for trend).

“This shift in management patterns away from radiation therapy and toward more radical prostatectomy is not supported by any recent high-level studies,” Mahal said. “This finding is provocative and may be a focal point of debate.”

A lack of data on active surveillance/watchful waiting compliance served as a limitation to this study.

“These findings capture the rapidly shifting landscape of management for localized prostate cancer and are suggestive of ‘management migration’ — where down-trending radical prostatectomy utilization in low-risk disease (in the setting of up-trending active surveillance/watchful waiting) may drive nonevidence-based management bias toward radical prostatectomy over radiotherapy in higher-risk disease,” the researchers wrote. “These national patterns serve as a targetable trend that should be addressed.” – by Jennifer Byrne

References:

Butler S, et al. Abstract 11. Scheduled for presentation at: Genitourinary Cancers Symposium; Feb. 14-16, 2019; San Francisco.

Mahal BA, et al. JAMA. 2019;doi:10.1001/jama.201819941.

Disclosures: Mahal reports no relevant disclosures. Please see the study and abstract for all other authors’ relevant financial disclosures.

Conservative prostate cancer management with active surveillance or watchful waiting increased significantly between 2010 and 2015 among men with low- and intermediate-risk localized disease, according to results of a SEER analysis published in JAMA and scheduled for presentation at Genitourinary Cancers Symposium.

The threefold increase among low-risk men — from 14.5% in 2010 to 42.1% in 2015 — made it the most commonly used approach in that patient population.

“What we know from high-level evidence is that conservative management of low-risk prostate cancer is associated with a very favorable prognosis,” Brandon A. Mahal, MD, clinical fellow in radiation oncology at Dana-Farber/Brigham and Women’s Cancer Center, said in a press release. “Many men with low-risk disease are able to be spared the toxicity of treatment so it’s an important discussion to have between clinicians and patients.”

Mahal and colleagues reviewed the custom SEER Prostate Active Surveillance/Watchful Waiting database to identify 164,760 men (median age, 64 years; interquartile range, 59-70; 16.2% black) with localized prostate cancer diagnosed between 2010 and 2015 who had a known management strategy.

Among these men, 20,879 (12.7%) used active surveillance/watchful waiting; 68,350 (41.5%) received radiotherapy; and 75,531 (45.8%) underwent radical prostatectomy.

Compared with men diagnosed in 2010 (n = 31,355), men diagnosed in 2015 (n = 25,140) had significantly lower rates of low-risk disease (24.5% vs. 34.2%), older median age (65 years vs. 64 years) and higher median PSA concentration (6.7 ng/mL vs. 6 ng/mL; P = .05 for all).

Among men with low-risk disease (n = 50,302), the researchers observed an increase from 2010 to 2015 in use of active surveillance/watchful waiting (14.5% to 42.1%) and decreases in use of radical prostatectomy (47.4% to 31.3%) and radiotherapy (38% to 26.6%; P < .001 for trend for all).

Men with intermediate-risk disease (n = 81,836) also demonstrated an increase in active surveillance/watchful waiting (5.8% to 9.6%, P < .001 for trend) and decreases in radical prostatectomy (51.8% to 50.6%, P = .004 for trend) and radiotherapy (42.4% to 39.8%, P < .001 for trend).

The use of active surveillance/watchful waiting remained consistent among men with high-risk disease (n = 32,622; 1.9% to 2.2%), whereas radical prostatectomy use increased from 38% to 42.8% (P < .001 for trend) and radiotherapy use decreased from 60.1% to 55% (P < .001 for trend).

“This shift in management patterns away from radiation therapy and toward more radical prostatectomy is not supported by any recent high-level studies,” Mahal said. “This finding is provocative and may be a focal point of debate.”

A lack of data on active surveillance/watchful waiting compliance served as a limitation to this study.

“These findings capture the rapidly shifting landscape of management for localized prostate cancer and are suggestive of ‘management migration’ — where down-trending radical prostatectomy utilization in low-risk disease (in the setting of up-trending active surveillance/watchful waiting) may drive nonevidence-based management bias toward radical prostatectomy over radiotherapy in higher-risk disease,” the researchers wrote. “These national patterns serve as a targetable trend that should be addressed.” – by Jennifer Byrne

References:

Butler S, et al. Abstract 11. Scheduled for presentation at: Genitourinary Cancers Symposium; Feb. 14-16, 2019; San Francisco.

Mahal BA, et al. JAMA. 2019;doi:10.1001/jama.201819941.

Disclosures: Mahal reports no relevant disclosures. Please see the study and abstract for all other authors’ relevant financial disclosures.

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