More judicious use of expectant management for localized prostate cancer over the past two decades

Urologists have been criticized for over-treating men with low-risk prostate cancer, and for passively observing older men with higher-risk disease. Proponents of active surveillance (AS) for low-risk disease and critics of watchful waiting (WW) for higher-risk disease have advocated for more judicious use of observation. Thus, we compared two population-based cohorts to determine how expectant management has evolved over the past two decades.

5,871 men with localized prostate cancer were enrolled in the Prostate Cancer Outcomes Study (PCOS: 1994 to 1995) or the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR: 2011 to 2012) study. We compared use of definitive treatment vs. expectant management (WW/AS) across cohorts, focusing on the influence of disease risk, age and comorbidities.

Use of WW/AS was similar in PCOS and CEASAR (14% in each). Compared to PCOS, more men in CEASAR with low-risk disease selected WW/AS (25% vs. 15%, respectively), whereas fewer men with intermediate- (7% vs. 14%) and high-risk (3% vs. 10%) disease chose WW/AS (p<0.001 for each). The association of disease risk with WW/AS was significantly larger in CEASAR than PCOS (OR, 7.3; 95% confidence interval [CI], 3.4 to 15.7). Older age was associated with WW/AS in both cohorts, but there was no association between comorbidity and WW/AS in CEASAR.

Use of WW/AS was more aligned with disease risk in CEASAR compared PCOS, suggesting there has been a pivot from WW to AS. While older men were more likely to be observed, comorbidity had little, if any, influence.

The Journal of urology. 2016 Oct 27 [Epub ahead of print]

J B Eifler, J Alvarez, T Koyama, R M Conwill, C R Ritch, K E Hoffman, M J Resnick, D F Penson, D A Barocas

Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA., Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA., Department of Urology, University of Miami Health System, Miami, FL, USA., Department of Radiation Oncology, University of Texas MD Anderson Cancer Center., Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address: .

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