Use of Expectant Management Lags in Prostate Cancer

Expectant management is widely underused in the treatment of prostate cancer in the United States, according to a paper presented today during the 2013 Annual Meeting of the American Urological Association in San Diego.

Fewer than 10% of American men with newly diagnosed prostate cancer opted for expectant management in the first 10 years of this century, including the low-risk and older men most likely to benefit from the strategy, an author of the paper, Matthew Maurice, MD, at Case Western Reserve University, explained during the presentation.

Expectant management includes active surveillance and watchful waiting, and is meant to minimize the overtreatment of prostate cancer, Maurice and co-author Hui Zhu, MD wrote.

“Given estimates of prostate cancer overdiagnosis as high as 40%, expectant management has been persistently underutilized, even in patients with low-stage cancers and limited life expectancy,” Maurice said. “This is an alarming trend, given the high-level evidence to support its use.

In an analysis of the National Cancer Database, the authors found that the annual use of expectant management in America remained stable at between 7.5% and 9.8% from 2000 through 2009. However, they reported, employment of the strategy increased significantly within the Veterans Affairs (VA) health system, where rises were seen in categories for which expectant management is most appropriate.

“VA hospitals led US hospitals in the use of expectant management, especially in men well-suited for this approach, while hospitals relying on third-party payers lagged behind,” Maurice said. “The reasons for this pattern are likely multifactorial, possibly involving economic factors, technology factors, and patient-driven factors.”

Maurice and colleagues queried the database—which included about 70% of newly diagnosed cancers in the United States—regarding prostate cancers diagnosed from 2000 to 2009 and the first-course therapy employed in each case. They evaluated the use of expectant management by patient risk, age, comorbidity burden, and practice setting.

The only major increase in expectant management occurred in the VA system, where the proportion of prostate cancer patients who opted for the tactic increased from 19.7% at the beginning of the study period to 30.8% at the end. The total use of expectant management in the VA system included 53.7% of all patients with stage I prostate cancer, 28% of patients 70 or older, and 27% of patients with two or more comorbid conditions.

In contrast, the lowest rates of expectant management were seen in comprehensive cancer centers, where the strategy was used in about 9% of stage I cancers, 9% of patients with two or more comorbid conditions, and 8.5% of patients 70 or older.

The authors suggested that “the type of reimbursement system may play an important role in EM adoption,” a possibility they said should be studied further to avoid the overtreatment of prostate cancer.

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View coverage from the 2013 AUA Annual Meeting

Maurice M, Zhu H. Persistent Underutilization of Expectant Management for Prostate Cancer Last Decade in the United States. Presented at: The 2013 Annual Meeting of the American Urological Association; May 4-8, 2013; San Diego, California. Abstract 220.