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Trends and practices for managing low-risk prostate cancer: a SEER-Medicare study

Prostate Cancer and Prostatic Diseases volume 25, pages 100–108 (2022)Cite this article

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Abstract

Background

Expectant management (EM) has been widely recommended for men with low-risk prostate cancers (PCa). We evaluated trends in EM and the sociodemographic and clinical factors associated with EM, initiating a National Comprehensive Cancer Network guideline-concordant active surveillance (AS) monitoring protocol, and switching from EM to active treatment (AT).

Methods

We used the SEER-Medicare database to identify men ages 66+ diagnosed with a low-risk PCa (PSA < 10 ng/mL, Gleason ≤ 6, stage ≤ T2a) in 2010–2013 with ≥1 year of follow-up. We used claims data to capture (1) PCa treatments, including surgical procedures, radiotherapy, and hormone therapy, and (2) AS monitoring procedures, including PSA tests and prostate biopsy. We defined EM as receiving no AT within 1 year of diagnosis. We used multivariable regression techniques to identify factors associated with EM, initiating AS monitoring, and switching to AT.

Results

During the study period, EM increased from 29.4% to 49.0%, p < 0.01. Age < 77, being married/partnered, non-Hispanic ethnicity, higher median ZIP code income, lower PSA levels, stage T1c, and more recent year of diagnosis were associated with EM. Nearly 39% of the EM cohort initiated AS monitoring; age <77, White race, being married/partnered, higher median ZIP code income, and lower PSA levels were associated with initiating AS. By three years after diagnosis, 21.3% of the EM cohort had switched to AT, usually after undergoing AS monitoring procedures.

Discussion

We found increasing uptake of EM over time, though over 50% still received AT. About 60% of EM patients did not initiate AS monitoring, even among those with life expectancy >10 years, implying that a substantial proportion was being managed by watchful waiting. AS monitoring was associated with switching to AT, suggesting that treatment decisions likely were based on cancer progression.

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Data availability

The data that support the findings of this study are available from the National Cancer Institute, but restrictions apply to the availability of these data, which are under license for the study, and so are not publicly available.

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Acknowledgements

This work was supported by the University of Iowa Holden Comprehensive Cancer Center Population Research and Biostatistics Cores and the National Cancer Institute (P30 CA086862; R50 CA243692). This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database. The collection of cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute’s Surveillance, Epidemiology and End Results Program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California, and contract HHSN261201000034C awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement # U58DP003862-01 awarded to the California Department of Public Health. The ideas and opinions expressed herein are those of the author(s) and endorsement by the State of California Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

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Authors and Affiliations

  1. Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA

    Richard M. Hoffman

  2. Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA

    Richard M. Hoffman, Sarah L. Mott, Bradley D. McDowell & Kenneth G. Nepple

  3. Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA

    Richard M. Hoffman, Sarah L. Mott, Bradley D. McDowell & Sonia T. Anand

  4. Department of Urology, University of Iowa Carver College of Medicine, Iowa City, IA, USA

    Kenneth G. Nepple

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Correspondence to Richard M. Hoffman.

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The authors declare no competing interests.

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The research project was approved by the University of Iowa Human Subjects Review Board, IRB number 01. The study was performed in accordance with the Declaration of Helsinki.

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Hoffman, R.M., Mott, S.L., McDowell, B.D. et al. Trends and practices for managing low-risk prostate cancer: a SEER-Medicare study. Prostate Cancer Prostatic Dis 25, 100–108 (2022). https://doi.org/10.1038/s41391-021-00393-6

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