Presentation Authors: Stacy Loeb*, Danil Makarov, Nataliya Byrne, Dawn Walter, NEW YORK, NY
Introduction: Current guidelines describe conservative management as the best available care option for very low-risk prostate cancer (VLR; i.e. low volume, low-risk prostate cancer) and also the preferred option for low-not-very-low risk disease (LR not VLR), while acknowledging that definitive treatment may be warranted for those with a higher probability of disease progression. Our objective was to examine the trends in use of conservative management for VLR and LR not VLR prostate cancer separately to determine whether national practice variation is driven by the more guideline-concordant practice of occasional treatment of low risk disease.
Methods: Using the VA Central Data Warehouse from 2010-2015, we identified 8521 men diagnosed with VLR prostate cancer (PSA less than 10, stage cT1/T2a, and Gleason less than or equal to 6 in less than or equal to 2 biopsy cores) and 4906 men with LR not VLR disease (PSA less than 10, stage cT1/T2a, and Gleason 6 or less in more than 2 biopsy cores). Descriptive statistics were used to determine the proportion of men managed by active surveillance (at least 2 PSAs and 1 biopsy within 2 years after diagnosis) versus watchful waiting. Multivariable logistic regression was used to identify factors associated with receipt of conservative management in the VLR group.
Results: In our cohort, the use of conservative management for VLR prostate cancer increased from 59% in 2010 to 85% in 2015 (Figure). This was primarily due to an increase in the use of active surveillance, from 29% to 46%, accompanied by a similar decline in radical prostatectomy and radiation therapy. However, throughout this period there was significant variation between VA facilities in the proportion of VLR receiving conservative management, ranging from 26% to 100%. On multivariable analysis, older age, unmarried status, more comorbidities, later year of diagnosis, lowest prostate cancer case volume, and certain regions were significantly associated with increased use of conservative management in the VLR group. Use of conservative management also increased over time in the LR not VLR group, but remained lower than for VLR.
Conclusions: The majority of low-risk prostate cancers are currently managed conservatively in the VA system, particularly VLR. However, even in this highly selected patient population there remains significant institution-level variation.
Source of Funding: This study was supported by The Edward Blank and Sharon Cosloy-Blank Family Foundation, The Gertrude and Louis Feil Family, the New York State Department of Health (#DOH01-C30697GG-3450000), The Laura and Isaac Perlmutter Cancer Center at NYU Langone Medi