Use and Predictors of Expectant Management of Low and Intermediate Risk Localized Prostate Cancer in Elderly Men

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IntroductionExpectant management reduces overtreatment in low risk but not intermediate risk localized prostate cancer. We assessed the use and predictors of expectant management to understand its uptake in practice in the United States. MethodsUsing the SEER (Surveillance, Epidemiology and End Results)-Medicare database, we conducted a retrospective cohort study of men 66 years or older diagnosed with low (25,506 patients) or intermediate risk (25,597) localized prostate cancer between 2004 and 2011 and followed through December 31, 2012. We defined expectant management as 1) no definitive therapy and at least 1 prostate specific antigen test or repeat biopsy 4 to 12 months after diagnosis or 2) receiving definitive therapy after prostate specific antigen testing or repeat biopsy 7 to 12 months after diagnosis. We performed separate analyses for low and intermediate risk groups using multiple logistic regressions. ResultsFor men diagnosed with prostate cancer in 2004 to 2011 expectant management increased from 22% to 43% in the low risk group and from 15% to 18% in the intermediate risk group. In the low risk group expectant management increased with age (adjusted OR 1.26 for age 71 to 75 years, 2.21 for 76 to 80 years, 6.33 for greater than 80 years; all p <0.0001 compared to age 66 to 70 years). Expectant management uptake was higher among men with comorbidities (OR 1.29) and those residing in the Pacific region (adjusted OR 0.56 compared to East Coast). ConclusionsIn United States practice utilization of expectant management has steadily increased in low risk prostate cancer and remained low in intermediate risk prostate cancer through time. While men with comorbidities or advanced age were more likely to undergo expectant management, its use varied substantially by geographic region. Our findings bring attention to the presence of multiple barriers to expectant management implementation.