Patient and Context Factors in the Adoption of Active Surveillance for Low-Risk Prostate Cancer
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Published:2023-10-17
Issue:10
Volume:6
Page:e2338039
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ISSN:2574-3805
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Container-title:JAMA Network Open
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language:en
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Short-container-title:JAMA Netw Open
Author:
Ciccone Giovannino1, De Luca Stefano2, Oderda Marco3, Munoz Fernando4, Krengli Marco5, Allis Simona6, Baima Carlo Giuliano7, Barale Maurizio8, Bartoncini Sara9, Beldì Debora5, Bellei Luca10, Bellissimo Andrea Rocco11, Bernardi Diego12, Biamino Giorgio13, Billia Michele14, Borsa Roberto15, Cante Domenico16, Castelli Emanuele17, Cattaneo Giovanni2, Centrella Danilo18, Collura Devis19, Coppola Pietro15, Dalmasso Ettore12, Di Stasio Andrea20, Fasolis Giuseppe21, Fiorio Michele22, Garibaldi Elisabetta423, Girelli Giuseppe24, Griffa Daniele10, Guercio Stefano25, Migliari Roberto8, Molinaro Luca26, Montefiore Franco27, Montefusco Gabriele3, Moroni Maurizio28, Muto Giovanni29, Ponti di Sant’Angelo Francesca11, Ruggiero Luca27, Ruo Redda Maria Grazia30, Serao Armando20, Squeo Maria Sara31, Stancati Salvatore32, Surleti Domenico8, Varvello Francesco21, Volpe Alessandro14, Zaramella Stefano33, Zarrelli Giovanni13, Zitella Andrea3, Bollito Enrico34, Gontero Paolo3, Porpiglia Francesco2, Galassi Claudia1, Bertetto Oscar11, Alessio Manuela35, Annoscia Scipio35, Antonini Daniela35, Arrondini Marisa35, Baldassarre Emanuele35, Barbieri Paola35, Bardari Franco35, Belli Gaetano35, Bellina Maurizio35, Bellis Donata35, Bonini Fabio35, Bonvissuto Giulio35, Bosco Martino35, Bracco Francesco35, Brizio Rodolfo35, Brunetti Francesco35, Buffardi Andrea35, Cagnasso Silvia35, Cagnazzi Eugenio35, Calleris Giorgio35, Campisi Paola35, Caramanico Laura35, Carchedi Mariateresa35, Casalone Ugo35, Cassoni Paola35, Ceccarelli Manuela35, Chiapello Germano35, Cianini Elena35, Clot Francesca35, Cruciano Nicola35, Cussotto Michele35, De Angelis Paolo35, De Giuli Paolo35, Delmastro Elena35, Delsedime Luisa35, Di Martino Jessica35, Dogliani Natalia35, Ducret Chantal35, Erra Stefania35, Familiari Ubaldo35, Faraone Nicola35, Ferro Antonella35, Feyles Elda35, Fornari Alessandro35, Forte Giuseppe35, Fraire Flavio35, Francese Alessia35, Gabriele Pietro35, Galla Andrea35, Garrou Diletta35, Gatti Marco35, Giacobbe Alessandro35, Giacomelli Giuseppe35, Giordano Andrea35, Grande Susanna35, Guarneri Alessia35, Guglielmetti Sandro35, Guglielmini Pamela Francesca35, Iandolo Maria35, Iorio Giuseppe Carlo35, Ivaldi Paola35, Kurti Marisa35, La Porta Maria Rosa35, Leucci Giuliana35, Liberale Fabiola35, Lucci Chiarissi Marco35, Manassero Monica35, Manini Claudia35, Manzo Marco35, Marchioro Giansilvio35, Mari Mauro35, Maso Gloria35, Massa Federica35, Massarelli Massimo35, Melloni Guglielmo35, Mistrangelo Marinella35, Monagheddu Chiara35, Morabito Francesco35, Moro Gregorio35, Morra Ivano35, Negro Carlo35, Olivieri Valerio35, Orlassino Renzo35, Ortega Cinzia35, Pacchioni Donatella35, Pagani Alberto35, Pagano Marco35, Pagano Eva35, Papotti Mauro35, Pasquale Massimo35, Patetta Roberta35, Pezzuto Valter35, Randone Donato35, Ricardi Umberto35, Ricci Daniele35, Rosato Rosalba35, Rossi Riccardo35, Rossi Cristina35, Rosso Diego35, Saccona Fabio35, Sedigh Omid35, Talarico Ezio35, Taraglio Stefano35, Taurino Matteo35, Treffiletti Salvatore35, Tucci Marcello35, Volante Marco35, Zavattero Carla Angela35, Zegna Luisa35,
Affiliation:
1. Epidemiologia Clinica e Valutativa, AOU Città della Salute e della Scienza di Torino e CPO Piemonte, Torino, Italy 2. Urologia, AOU San Luigi Gonzaga e Università di Torino, Orbassano, Italy 3. Urologia, AOU Città della Salute e della Scienza e Università di Torino, Torino, Italy 4. Radioterapia, PO Umberto Parini, Aosta, Italy 5. Radioterapia, AOU Maggiore della Carità e Università del Piemonte Orientale, Novara, Italy 6. Radioterapia, AOU San Luigi Gonzaga, Orbassano, Italy 7. Urologia, Ospedali Riuniti ASL TO4, Ciriè, Italy 8. Urologia, AO Ordine Mauriziano, Torino, Italy 9. Radioterapia, AOU Città della Salute e della Scienza e Università di Torino, Torino, Italy 10. Urologia, Ospedali Riuniti ASL TO4, Ivrea, Italy 11. Rete Oncologica del Piemonte e Valle d’Aosta, AOU Città della Salute e della Scienza di Torino, Torino, Italy 12. Urologia, AO Santa Croce e Carle, Cuneo, Italy 13. Urologia, PO Cardinal Massaia, Asti, Italy 14. Urologia, AOU Maggiore della Carità e Università del Piemonte Orientale, Novara, Italy 15. Urologia, PO SS Annunziata, Savigliano, Italy 16. Radioterapia, ASL TO4, Ospedale di Ivrea, Ivrea, Italy 17. Urologia, PO Umberto Parini, Aosta, Italy 18. Urologia, PO San Biagio, Domodossola, Italy 19. Urologia, PO Humanitas Gradenigo, Torino, Italy 20. Urologia, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy 21. Urologia, PO Michele e Pietro Ferrero, Verduno, Italy 22. Urologia, PO San Giovanni Bosco, Torino, Italy 23. Radioterapia, Istituto di Candiolo-Fondazione del Piemonte per l’Oncologia (FPO), IRCCS, Candiolo, Italy 24. Radioterapia, PO Nuovo Ospedale degli Infermi, Ponderano, Italy 25. Urologia, PO Edoardo Agnelli, Penerolo, Italy 26. Anatomia Patologica 1U, AOU Città della Salute e della Scienza di Torino, Torino, Italy 27. Urologia, PO San Giacomo, Novi Ligure, Italy 28. Urologia, PO Maria Vittoria, Torino, Italy 29. Urologia, Ospedale Maria Pia, Torino, Italy 30. Radioterapia, AO Ordine Mauriziano e Università di Torino, Torino, Italy 31. Urologia, PO Martini, Torino, Italy 32. Urologia, PO Rivoli, Rivoli, Italy 33. Urologia, PO Nuovo Ospedale degli Infermi, Ponderano, Italy 34. Anatomia Patologica, AOU San Luigi Gonzaga e Università di Torino, Orbassano, Italy 35. for the START Collaborative Group
Abstract
ImportanceAlthough active surveillance for patients with low-risk prostate cancer (LRPC) has been recommended for years, its adoption at the population level is often limited.ObjectiveTo make active surveillance available for patients with LRPC using a research framework and to compare patient characteristics and clinical outcomes between those who receive active surveillance vs radical treatments at diagnosis.Design, Setting, and ParticipantsThis population-based, prospective cohort study was designed by a large multidisciplinary group of specialists and patients’ representatives. The study was conducted within all 18 urology centers and 7 radiation oncology centers in the Piemonte and Valle d’Aosta Regional Oncology Network in Northwest Italy (approximate population, 4.5 million). Participants included patients with a new diagnosis of LRPC from June 2015 to December 2021. Data were analyzed from January to May 2023.ExposureAt diagnosis, all patients were informed of the available treatment options by the urologist and received an information leaflet describing the benefits and risks of active surveillance compared with active treatments, either radical prostatectomy (RP) or radiation treatment (RT). Patients choosing active surveillance were actively monitored with regular prostate-specific antigen testing, clinical examinations, and a rebiopsy at 12 months.Main Outcomes and MeasuresOutcomes of interest were proportion of patients choosing active surveillance or radical treatments, overall survival, and, for patients in active surveillance, treatment-free survival. Comparisons were analyzed with multivariable logistic or Cox models, considering centers as clusters.ResultsA total of 852 male patients (median [IQR] age, 70 [64-74] years) were included, and 706 patients (82.9%) chose active surveillance, with an increasing trend over time; 109 patients (12.8%) chose RP, and 37 patients (4.3%) chose RT. Median (IQR) follow-up was 57 (41-76) months. Worse prostate cancer prognostic factors were negatively associated with choosing active surveillance (eg, stage T2a vs T1c: odds ratio [OR], 0.51; 95% CI, 0.28-0.93), while patients who were older (eg, age ≥75 vs <65 years: OR, 4.27; 95% CI, 1.98-9.22), had higher comorbidity (Charlson Comorbidity Index ≥2 vs 0: OR, 1.98; 95% CI, 1.02-3.85), underwent an independent revision of the first prostate biopsy (OR, 2.35; 95% CI, 1.26-4.38) or underwent a multidisciplinary assessment (OR, 2.65; 95% CI, 1.38-5.11) were more likely to choose active surveillance vs active treatment. After adjustment, center at which a patient was treated continued to be an important factor in the choice of treatment (intraclass correlation coefficient, 18.6%). No differences were detected in overall survival between active treatment and active surveillance. Treatment-free survival in the active surveillance cohort was 59.0% (95% CI, 54.8%-62.9%) at 24 months, 54.5% (95% CI, 50.2%-58.6%) at 36 months, and 47.0% (95% CI, 42.2%-51.7%) at 48 months.Conclusions and RelevanceIn this population-based cohort study of patients with LRPC, a research framework at system level as well as favorable prognostic factors, a multidisciplinary approach, and an independent review of the first prostate biopsy at patient-level were positively associated with high uptake of active surveillance, a practice largely underused before this study.
Publisher
American Medical Association (AMA)
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