A recent study led by NYU School of Medicine and Manhattan VA NY Harbor Healthcare System researchers reveals that conservative management has become the preferred management option for U.S. veterans with low-risk prostate cancer. The findings signal that after decades of overtreatment for low-grade tumors, more physicians appear to be heeding best practice guidelines.

More Guideline-Concordant Care

The investigation was led by Stacy Loeb, MD, assistant professor in the Departments of Urology and Population Health at NYU Langone Health, an attending urologist at the Manhattan VA, and a member of Perlmutter Cancer Center at NYU Langone Health. Her team found that patients with low-grade tumors were far less likely to pursue aggressive treatment in 2015 than in 2005—a period when prostate-specific antigen (PSA) testing came under increasing criticism for inducing over-diagnosis leading to unnecessary treatments. Findings were published in the May 15, 2018 issue of Journal of the American Medical Association.

“This marks a historic reversal, at least at the VA, in the decades-long overtreatment of men with prostate cancers least likely to cause harm,” says Dr. Loeb. “It brings their care more in line with the latest best practice guidelines, such as those of the American Society of Clinical Oncology and American Urological Association, which discourage aggressive therapy for low-grade tumors.”

“This marks a historic reversal, at least at the VA, in the decades-long overtreatment of men with prostate cancers least likely to cause harm.”—Stacy Loeb, MD 

The study, one of the largest to date examining U.S. treatment patterns for low-risk disease, was based on an analysis of more than 125,000 patient records contained in the VA’s Central Data Warehouse. Patients had a mean age of 64 and mean PSA of 5.4 ng/mL. 

Conservative Management Increasing in All Age Groups

Researchers noted a substantial rise in the use of active surveillance during the study period across all age groups. During the study period, the percentage of men younger than age 65 who opted for watchful waiting or active surveillance over surgery jumped from 27 percent to 72 percent, with a similar increase seen among older patients.

During the study period, the percentage of men younger than age 65 who opted for watchful waiting or active surveillance over surgery jumped from 27 percent to 72 percent, with a similar increase seen among older patients.

Conservative management overall was more likely for men who were black, older age, unmarried, higher PSA, increasing comorbidity, and living in certain geographic regions. Among men choosing conservative management, those older than 75 years, with higher PSA scores, and with greater comorbidity were more likely to receive watchful waiting as opposed to active surveillance.

VA’s Success Mirrors Sweden’s Model of High-Quality, Value-Based Care

In light of published data, the findings indicate that overtreatment has become less of a problem at the VA than at other U.S. healthcare settings, researchers noted. For example, only 32 percent of patients received conservative management in the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database from 2010 to 2011. Similarly, 2010 to 2013 data from a registry of 45 community-based urology practices show that 40 percent of patients were managed conservatively.

During the study period, the percentage of men younger than age 65 who opted for watchful waiting or active surveillance over surgery jumped from 27 percent to 72 percent, with a similar increase seen among older patients.

The VA’s success in improving the standard of care for low-risk prostate cancer patients is comparable to data from countries known for providing high-quality, value-based care, said Dr. Loeb. Sweden, for example, reported 74 percent of patients undergoing active surveillance in 2014.

Despite the trend toward best practice adherence, certain circumstances may lead patients to prefer immediate treatment, such as an infection following the initial biopsy, says Dr. Loeb. The important point, she stresses, is for physicians and patients to carefully review all options and risks upfront and engage in shared decision-making.

“The main conclusion to be drawn from the data is that most veterans with low-risk prostate cancer are now adopting conservative management, and other American men might follow suit if counseled on the potential benefits,” says Dr. Loeb. With funding from the Prostate Cancer Foundation, Dr. Loeb and her team are creating additional tools and online education materials to improve active surveillance.

Funding/Support: This study was supported by the Edward Blank and Sharon Cosloy Blank Family Foundation, the Gertrude and Louis Feil Family; and by grants DOH01-C30697GG-3450000 from the New York State Department of Health, P30CA016087 from the Laura and Isaac Perlmutter Cancer Center at NYU Langone, the Prostate Cancer Foundation, K07CA178258 from the National Institutes of Health (NIH) (Dr. Loeb), and CDA11-257 and CDP 11-254 from the US Department of Veterans Affairs (Dr. Makarov).

Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Loeb reported consulting for Lilly, MDx Health, GenomeDx, and General Electric and receiving personal fees from Astellas, Sanofi, Minomic, and Boehringer Ingelheim. Dr. Makarov reported consulting for the US Food and Drug Administration. Dr. Lepor reported previously holding shares in SonaCare Medical and receiving research support from and serving on the advisory board for Genomic Health. No other disclosures were reported.