The following is a summary of “Use of expectant management based on prostate cancer risk and health status: How far are we from a risk-adapted approach?,” published in the July 2023 issue of the Urologic Oncology by Spratte et al.

Although active surveillance, a form of expectant management (EM), is favored for low-risk prostate cancer (PCa) patients, some prefer a risk-adapted approach considering patient preferences and condition-specific factors. However, prior research has demonstrated that non-patient-related factors frequently influence PCa treatment. In this context, the researchers characterized AS trends regarding disease risk and health conditions. They examined receipt of EM, defined as the absence of treatment (i.e., surgery, cryotherapy, radiation, chemotherapy, and androgen deprivation therapies) within 1 year of diagnosis among men 66 years and older diagnosed with localized low- and intermediate-risk PCa from 2008 to 2017. 

They compared trends in the use of EM versus treatment stratified by disease risk (i.e., Gleason 3+3, 3+4, 4+3; PSA<10, 10–20) and health status (i.e., NCI Comorbidity Index (NCI), frailty, life expectancy) using bivariable analysis. Then, they employed a multivariable logistic regression model to investigate EM’s determinants. In this cohort, 26,364 (38%) were classified as low-risk (i.e., Gleason 3+3 and PSA<10), and 43,520 (62%) were classified as intermediate-risk (i.e., all others). During the study period, the use of EM increased substantially across all risk groups, except Gleason 4+3 (P = 0.662), and across all health status groups. However, linear trends did not dramatically differ between frail and non-frail patients categorized as low-risk (P = 0.446) or intermediate-risk (P = 0.208). Trends did not vary between NCI 0 vs. 1 vs.>1 for low-risk PCa (P = 0.395). 

In multivariable models, EM was associated with increasing age and frailty in men with low and intermediate disease risk. In contrast, EM selection was inversely related to a higher comorbidity score. EM increased significantly over time in patients with low- and favorable intermediate-risk disease, with age and Gleason score accounting for the most notable differences. In contrast, no significant differences in EM utilization by health status indicated that physicians may not effectively incorporate patient health into PCa treatment decisions. Developing interventions that recognize health status as an essential component of a risk-adapted approach requires additional effort.

Source: sciencedirect.com/science/article/abs/pii/S1078143923001230