Introduction

To assess utilization of active surveillance in men with low-risk prostate cancer at Commission on Cancer designated facilities and to evaluate the influence of institutional factors associated with receipt of active surveillance.

Methods

Retrospective cohort of 40,215 men within the National Cancer Data Base, with low-risk prostate cancer, as defined by National Comprehensive Cancer Network guidelines, diagnosed between 2012 and 2013. Multivariable and mixed-effects models were used to examine variation and factors associated with active surveillance.

Results

Between 2012 and 2013 the overall rate of active surveillance was 14%. Unadjusted proportion of patients eligible for active surveillance ranged from 0% to 100%. The adjusted probability of active surveillance receipt by institution varied from 0% to 53%. Mean adjusted probability of receiving active surveillance was 0.033 (95% confidence interval [CI] 0.023-0.256). Relative to patients treated at Comprehensive Community Cancer Centers patients treated at Community Cancer Programs and academic institutions had higher odds of receiving active surveillance (odds ratio [OR] 2.74, 95% CI 1.94-3.88; p<0.001 and OR 2.50 95%, CI 1.77-3.54; p<0.001, respectively). Relative to patients treated at very low volume facilities, patients treated at very-high volume facilities had higher odds of receiving active surveillance (OR 3.50, 95%CI 1.84-6.68; p<0.001). Patient and hospital-level variables accounted for 41% of the overall variation, whereas the treating institution accounted for 35% of the unexplained variability.

Conclusions

The overall use of active surveillance at Commission on Cancer designated facilities remains low at 14%. Significant variation in the use of active surveillance was seen across facilities with patients treated at academic and very high volume centers being more likely to receive active surveillance. A non-negligible proportion of the variation is explained by the treating institution. Given the current concerns for overdiagnosis and overtreatment of indolent prostate cancer, policies need to be implemented to achieve higher rates of active surveillance in prostate cancer patients when appropriate.

Funding

none