Dotted line indicates reference group.
aOnly facilities reporting to the NCDB for each year of the study period were included in the analysis.
The P values compare the time trends in specific treatment groups with that in the reference group. For example, in the high-risk prostate cancer cohort, the time trend for active treatment (TX) (relative to hormonal therapy [ADT], the referent) was significant at P < .01. By comparison, the time trend for watchful waiting (WW) (relative to ADT, the referent) was not significant at P = .76. Finally, the time trend for active surveillance (AS) (relative to ADT, the referent) was significant at P < .01. In Figure 1, intermediate-risk prostate cancer is the reference group. Therefore, the trends for low-risk prostate cancer and high-risk prostate cancer are being compared with the trend for intermediate-risk prostate cancer.
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Maurice MJ, Kim SP, Abouassaly R. Current Status of Prostate Cancer Diagnosis and Management in the United States. JAMA Oncol. 2016;2(11):1505–1507. doi:10.1001/jamaoncol.2016.1785
In 2012, the US Preventative Services Task Force (USPSTF) recommended against prostate cancer (PC) screening to address overdiagnosis and overtreatment. In response, PC screening and the incidence of localized PC have declined.1 If the USPSTF recommendations were fully implemented, it would eliminate overdiagnosis at the expense of increasing preventable PC deaths.2 Active surveillance also addresses overdiagnosis and, if executed properly, can safely reduce overtreatment by as much as 50%.3 Unlike watchful waiting, which avoids curative treatment entirely, active surveillance involves prospective monitoring of low-risk PC and selective treatment for apparent progression. Prior to the 2012 USPSTF recommendation, active surveillance use was minimal.4 We sought to assess current PC diagnosis and management trends in the United States. The analysis was complete on February 1, 2016. Institutional review board approval was obtained from University Hospitals Case Medical Center prior to study initiation.
Using the US National Cancer Data Base, a nationwide hospital-based cancer registry that captures 70% of PC diagnoses, we identified incident cases of clinically localized (cT1-3a, N0, M0) PC from 2010 to 2013. D’Amico criteria were used for PC risk stratification: low-risk (cT1-T2a, Gleason score ≤6, prostate-specific antigen [PSA] level <10 ng/mL), intermediate-risk (cT2b, Gleason score 7, PSA level 10-20 ng/mL), and high-risk (cT2c-3a, Gleason score ≥8, PSA level >20 ng/mL). Prostate cancer treatments were classified as active surveillance, watchful waiting, hormonal therapy alone (ADT), and active treatment, including surgery and/or radiation therapy with or without ADT. Diagnosis and treatment time trends were analyzed using multinomial logistic regression with intermediate-risk PC and ADT as the reference groups, respectively. SAS University Edition statistical software (SAS Institute Inc) was used. P <.05 was considered statistically significant.
Prostate cancer diagnoses decreased at an average rate of 7200 cases per year from a high of 90 419 cases in 2011 to a nadir of 71 945 cases in 2013. This decline was observed across all age groups and risk groups but was greatest for men younger than 70 years and for low-risk disease, for which PC diagnoses decreased by 21% and 36%, respectively. Low-risk and high-risk PC diagnoses decreased significantly over time for men of all ages but especially in men younger than 70 years (Figure 1).
For low-risk PC, the use of active surveillance (range, 7.4%-18.4%) and watchful waiting (range, 3.9%-5.2%) increased significantly over time, while active treatment decreased (range, 73.0%-83.6%) (Figure 2). Relative to active treatment, there was 1.4-fold higher odds of active surveillance (odds ratio [OR], 1.4; 95% CI, 1.4-1.4; P < .01) and 1.2-fold higher odds of watchful waiting (OR, 1.2; 95% CI, 1.1-1.2; P < .01) per year. Active surveillance and watchful waiting use also increased significantly for intermediate-risk disease but to a lesser extent (P < .01). For high-risk PC, active treatment use decreased significantly over time (range, 59.0%-64.4%), while the use of active surveillance (range, 1.2%-1.8%) and ADT (range, 30.6%-34.8%) increased significantly. Relative to ADT, the odds of receiving active treatment for high-risk PC were 7% lower per year (OR, 0.93; 95% CI, 0.92-0.94; P < .01).
Since the 2011-2012 USPSTF recommendation, localized PC diagnosis declined by over 20%, mirroring recent population-based trends.1 Although PC detection decreased most for low-risk disease, the incidence of high-risk PC also decreased, suggesting underdiagnosis.2 Decreased detection of lethal PC, especially among younger men, represents a possible missed opportunity for curative treatment. This alarming trend suggests that if the USPSTF recommendation is followed, more high-risk PC will go undetected and more men with potentially treatable cancers will experience PC morbidity and mortality.
Low-risk PC is increasingly being managed with active surveillance, which now accounts for nearly 20% of cases, demonstrating the feasibility of limiting overtreatment at the patient and provider level. Alternatively, high-risk PC is being treated less frequently, contrary to level 1 evidence, possibly owing to overtreatment fears incited by the USPSTF.5,6
Strengths of our study are the large sample size, inclusion of all-aged men, and stratification by PC risk group. Limitations include the retrospective design and susceptibility to selection bias.
The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology used, or the conclusions drawn from these data by the investigators.
Corresponding Author: Robert Abouassaly, MD, MS, Urology Institute, University Hospitals Case Medical Center, 11100 Euclid Ave, Mailstop LKS 5046, Office 4565, Cleveland, OH 44106 (email@example.com).
Published Online: June 23, 2016. doi:10.1001/jamaoncol.2016.1785.
Author Contributions: Dr Abouassaly had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Maurice, Abouassaly.
Drafting of the manuscript: Maurice, Abouassaly.
Critical revision of the manuscript for important intellectual content: Kim, Abouassaly.
Statistical analysis: Maurice, Abouassaly.
Study supervision: Kim, Abouassaly.
Conflict of Interest Disclosures: None reported.
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