The practice of active surveillance for prostate cancer: Trends, variation, and quality within a large national health system.

Abstract

347 Background: Active surveillance (AS) is broadly endorsed as preferred management for low-grade prostate cancer, but few data exist regarding variation and potential disparity in the use of AS interventions. This study characterizes the practice of AS broadly and deeply in the national VA Health Care System (VAHCS) in order to evaluate the adoption of AS for veterans with low and favorable intermediate risk prostate cancer. Methods: Pathology reports for biopsies, radiology reports for MRIs, and clinical and demographic data were collected from the VA Corporate Data Warehouse (CDW) for patients listed in the VA Informatics and Computing Infrastructure (VINCI) Prostate Data Core. The cohort includes patients with Gleason Grade Group (GG) 1 prostate cancer or GG 2 prostate cancer with less than 50% positive cores at diagnostic biopsy (DBx), as determined from pathology reports using natural language processing (NLP). Patients were stratified by whether they received treatment (radiation, prostatectomy, and/or orchiectomy/ADT) during the first 15 months or remained on AS or watchful waiting (WW). Patients with at least one PSA > 1 ng/mL or a confirmatory biopsy (CBx) prior to treatment were classified as managed with AS/WW. Patients were censored due to death, progression to metastatic status, no recorded PSA labs within 15 months, or a reported PSA value < 1 ng/mL. Results: In total, there were 173,725 patients with a positive biopsy for prostate cancer between 2005 and 2024. Of these patients, 79,053 were diagnosed with GG 1 or GG 2 prostate cancer with less than 50% positive cores and were either managed with AS/WW or received treatment during the first 15 months after diagnosis. For GG 1 patients, the proportion on AS increased from 32% in 2005 to 92% in 2024, with an increase from 15% to 52% for patients diagnosed with GG 2 cancer. Treatment patterns varied across VA facilities, with the proportion treated through AS/WW ranging from 35%-100% for GG 1 and 8-88% for GG 2. Only 28% of AS patients received CBx within 15 months of diagnosis, with this rate peaking between 2012 and 2015. From 2015 to 2025, MRI-guided biopsy increased from 1% to 31% for DBx and from 5% to 36% for CBx. Conclusions: AS has become the primary disease management approach for low and favorable intermediate risk prostate cancer within the VAHCS. MRI-guided biopsy is a more recent phenomenon, with a constant increase in the number of patients receiving an MRI within the year prior to biopsy. These findings suggest the need for further research to compare quality of AS across facilities and examine outcomes of AS.