Importance: Many men with indolent prostate cancer often opt for radical prostatectomy or radiotherapy treatment for their disease. These men may experience considerable detriments of quality of life owing to sexual, urinary, and/or rectal toxic effects associated with these treatments. Without a better understanding of the mutable agents and predictors of treatment types, diffusion of expectant management among these men will be slow.
Objective: To determine population-based predictors for treatment and use of watchful waiting or active surveillance for indolent prostate cancer.
Design, setting, and participants: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. A total of 37,621 men in the general community diagnosed as having prostate cancer from 2004 to 2007 were followed until December 31, 2009.
Exposures: Watchful waiting or active surveillance, radiation therapy, or radical prostatectomy.
Main outcomes and measures: We used mixed-effects logistic regression analysis to determine the factors associated with aggressive treatment and use of watchful waiting or active surveillance for men with prostate cancer.
Results: The most common treatment type is radiation therapy (57.9% [95% CI, 57.4%-58.4%]), followed by radical prostatectomy (19.1% [95% CI, 18.7%-19.5%]) and watchful waiting or active surveillance (9.6% [95% CI, 9.3%-9.9%]). Moreover, patients and providers significantly integrate age (odds ratio [OR], 0.32 [95% CI, 0.29-0.35]) and comorbidities (OR, 0.62 [95% CI, 0.56-0.68]) when determining radical prostatectomy, while regional variation (OR, 0.57 [95% CI, 0.47-0.68]) and referral patterns (OR, 44.46 [95% CI, 41.04-48.17]) influence the use of radiation therapy. Patient demographics and tumor characteristics significantly account for 40% of patients undergoing prostatectomy, 12% choosing watchful waiting or active surveillance, and only 3% undergoing radiotherapy.
Conclusions and relevance: There is increased use of radiotherapy among patients with indolent prostate cancer with limited to no correlation with tumor biology. Active surveillance was underused, and a significant proportion of the variance was unexplained. Further research into qualitatively describing the contributing factors that drive decision-making recommendations for prostate cancer patients is needed.