Where patients with low-risk prostate cancer (PCa) reside may be associated with their risk for overtreatment of the malignancy as a result of underuse of active surveillance (AS), the preferred management option for most of these patients, findings from a recent study suggest.

An analysis of data from 79,825 men in the Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting (SEER-WW) database found that use of AS or watchful waiting (WW) as the initial reported management strategy for low-risk PCa increased from January 2010 to December 2015, but varied widely within and across the 17 SEER registry regions in the United States examined in the study. Results showed that 17% of the total variation in AS/WW use was explained by SEER region and observed county-level variables alone rather than clinical or patient factors, Samuel L. Washington III, MD, MAS, of the University of California, San Francisco, and colleagues reported in JAMA Network Open.

The overall rate of AS/WW use was 22.1%, but increased over time from 13.1% in 2010 to 32.5% in 2015. The San Francisco-Oakland and San Jose-Monterey regions had the highest rates (42.4% and 33.9%, respectively) and the rural Georgia and New Mexico regions had the lowest rates (4.1% and 9.3%, respectively).

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The mean annualized percent increase in AS/WW rates from 2010 to 2015 ranged from 6.3% in New Mexico to 81% in New Jersey.

Increasing age was associated with increased odds of AS/WW, whereas Hispanic ethnicity and Medicaid enrollment were associated with decreased odds. Compared with patients younger than 50 years, those aged 51-60, 61-70, and 71-80 years had significant 1.3-, 1.9-, and 2.3-fold increased odds of AS/WW. Hispanic men had significant 21% decreased odds of AS/WW compared with non-Hispanic White men. Patients with Medicaid coverage had significant 27% decreased odds of AS/WW compared with those who had private insurance and/or Medicare coverage.

The investigators found no association between AS/WW use and Black race, county-level socioeconomic factors, and specialist densities.

“The rates of AS and WW increased in the US through the first half of the 2010s, but in most regions remained below optimal levels,” the authors concluded. “Use of AS and WW varied substantially both across and within SEER regions, almost independent of patients- and county-level characteristics, such as socioeconomic factors or medical resources, reflecting local disparities in the awareness or acceptance of AS.”

Dr Washington and colleagues noted that SEER-WW data do not distinguish between AS and WW, so they excluded patients older than 80 years to decrease the likelihood of WW patients in their analysis.


Washington SL 3rd, Jeong CW, Lonergan PE, et al. Regional variation in active surveillance for low-risk prostate cancer in the US. Published online December 28, 2020. JAMA Netw Open. doi:10.1001/jamanetworkopen.2020.31349