Trends in active surveillance for very low‐risk prostate cancer: do guidelines influence modern practice?

As recommended by current NCCN guidelines, patients with very low‐risk prostate cancer may be treated with active surveillance ( AS ), but this may be underutilized. Using the National Cancer Database ( NCDB ), we identified men (2010–2013) with biopsy‐proven, very low‐risk prostate cancer that met AS criteria as suggested by Epstein (stage ≤ T1c; Gleason score ( GS ) ≤ 6; PSA  < 10; and ≤2 [or <33%] positive biopsy cores) and aged ≤76, and low comorbidity index (Charlson‐Deyo score = 0). For those patients meeting this criteria, we performed generalized estimation equation ( GEE ) method with incorporation of correlation in patients clustered within facility to determine the likelihood of undergoing AS . Among the 448 773 patients in the NCDB with low‐risk prostate cancer, 40 839 patients met the inclusion criteria. AS was utilized in 5798 patients (14.2%), while within the very low‐risk patients receiving treatment, up to 52.2% received radical prostatectomy. In univariate analyses, AS utilization was associated with older age, uninsured status (compared to private insurance), farther distance from facility, academic/research institutions and particularly in the New England region (all P  < 0.01). After adjustments of other predictors in multivariate analysis, patients preferentially received AS if they were older (all OR 's > 1 compared to younger groups), uninsured (vs. any insurance type, OR 's > 1); or treated at academic/research center ( OR  > 1). The overall use of AS increased from 11.6% (2010) to 27.3% (2013). We found a low, but rising rate of AS in a nationally representative group of very low‐risk prostate cancer patients. Disparities in the use of AS may be targeted to improve adherence to national guidelines.