br Results br Furthermore URO were also more likely to
.05). Furthermore, URO were also more likely to practice in a community-based clinic, receive reimbursement by a billing compensation structure, and have access to robot-assisted surgery compared to RO from the survey sample (all P < .05). Both spe-cialties responded as having a low level of access to a multidisci-plinary clinic.
Overall, 57.8% of all respondents also reported having > 15% of their patients clinically managed by AS, but URO had nearly twice the number of patients in this group compared to RO (Figure 1). In assessing specialists’ attitudes about AS for low-risk PCa, URO were more likely than RO to consider AS effective (92.0% vs. 86.5%, P ¼ .01; Figure 2). Additionally, half of RO viewed that patients had anxiety with AS compared to only a third of URO (49.5% vs. 29.4%; P < .001).
From case presentations of healthy patients diagnosed with low-risk PCa, clinical characteristics, physician specialty, and type of practice represented key aspects associated with recommendations of AS (Figures 3 and 4; Supplemental Table 1 in the online version). For instance, both specialties most commonly recommended AS for the older patient (75 years old) with low PSA (4 ng/dL) and low-
In this national survey, we sought to elucidate the perceived at-titudes and barriers regarding clinical factors (age, PSA, and number of positive cores) and physician characteristics associated with AS for low-risk PCa. Our study has several important findings about promoting implementation of AS for low-risk PCa. First, AS has gained broader acceptance as a disease management strategy for low-risk PCa among RO and URO. In a previous survey study, fewer RO and URO viewed AS effective for low-risk PCa (65.7% vs. 75.5%; P < .001) and felt comfortable recommending it APTSTAT3-9R to their patients (61.7% vs. 75.8%; P < .001).16 Furthermore, more RO than URO agreed that their low-risk patients were not interested in AS (82.3% vs. 59.1%; P < .001). In our study here, both specialties had a markedly higher response in perceiving AS to be effective and felt comfortable recommending it to their patients for low-risk
Clinical Genitourinary Cancer June 2019 - e475
Active Surveillance for PCa
Figure 3 Recommendations of AS Based on Clinical Scenarios Varying Age, PSA, and Prostate Biopsy Volume of Gleason 6 Prostate Cancer by Physician Specialty*
Abbreviations: AS ¼ active surveillance; PSA ¼ prostate-specific antigen. *P < .05.
disease (all > 85%). This led to more than half of the respondents stating that > 15% of their patients are managed by AS compared to only 8.8% and 21.9% of RO and URO, respectively. To that end, our study suggests that both specialties now view AS more favorably as a viable strategy for men diagnosed with low-risk PCa. Further evidence supporting broader acceptance of AS have been demonstrated in several population-based cohort studies as well. For instance, Cooperberg and Carroll15 documented a significant rise in AS for low-risk disease based on the Cancer of the Prostate Risk Assessment (CAPRA) score from 6.7% in 2009 to 40.4% in 2013. Similarly, the Michigan Urological Surgery Improvement Collabo-rative (MUSIC) found half of patients with low-risk PCa were managed with AS in 2013.2 However, recent National Cancer Data Base (NCDB) studies found substantially lower rates of AS from
inference is that AS has gradually become more utilized for low-risk
PCa, but greater efforts are needed to promote its use if desert biome is to become the preferred initial disease management strategy.
Second, our findings clearly show that patient age and the number of cores positive with Gleason 6 PCa affected the degree to which both specialties recommended AS. More specifically, few RO and URO endorsed AS for younger patients (55 years old) with 4 or more positive cores on prostate biopsy from the clinical presenta-tion. Therefore, these data suggest that younger age and higher volume Gleason 6 PCa constitute perceived barriers towards AS. Yet this reluctance to adopt AS as a preferred management strategy contrasts with several clinical trials and cohort studies suggesting that AS is safe for this subset of patients. For example, Leapman et al12 recently reported their institutional prospective database of 1433 men diagnosed with low-risk PCa and managed by AS at a median follow-up of 49 months. When stratified by age ( 60 years vs. > 60 years), younger men had lower 3- and 5-year rates of Gleason score upgrading on subsequent surveillance biopsies.