Determinants for choosing and adhering to active surveillance for localised prostate cancer: a nationwide population-based study

Abstract

ObjectiveKnowledge about factors influencing choice of and adherence to active surveillance (AS) for prostate cancer (PC) is scarce. We aim to identify which factors most affected choosing and adhering to AS and to quantify their relative importance.Design, setting and participantsIn 2015, we sent a questionnaire to all Swedish men aged ≤70 years registered in the National Prostate Cancer Register of Sweden who were diagnosed in 2008 with low-risk PC and had undergone prostatectomy, radiotherapy or started on AS.Outcome measurements and statistical analysisLogistic regression was used to calculate ORs with 95% CIs for factors potentially affecting choice and adherence to AS.Results1288 out of 1720 men (75%) responded, 451 (35%) chose AS and 837 (65%) underwent curative treatment. Of those starting on AS, 238 (53%) diverted to treatment within 7 years. Most men (83%) choose AS because ‘My doctor recommended AS’. Factors associated with choosing AS over treatment were older age (OR 1.81, 95% CI 1.29 to 2.54), a Charlson Comorbidity Index >2 (OR 1.50, 95% CI 1.06 to 2.13), being unaccompanied when notified of the cancer diagnosis (OR 1.45, 95% CI 1.11 to 1.89). Men with a higher prostate-specific antigen (PSA) at the time of diagnosis were less likely to adhere to AS (OR 0.26, 95% CI 0.10 to 0.63). The reason for having treatment after initial AS was ‘the PSA level was rising’ in 55% and biopsy findings in 36%.ConclusionsA doctor’s recommendation strongly affects which treatment is chosen for men with low-risk PC. Rising PSA values were the main factor for initiating treatment for men on AS. These findings need be considered by healthcare providers who wish to increase the uptake of and adherence to AS.

Simulation model of disease incidence driven by diagnostic activity

“…It is natural to define a proxy of the diagnostic activity using the incidence of lower risk (ie, low and intermediate risk) prostate cancer because such disease is more often asymptomatic 42,51 than higher risk disease, and because the incidence has increased threefold between 1992 and 2016, Figure S3, in line with the increase in use of PSA testing 25 . However, there are several others risk categorization systems, and some could be more predictive of prostate cancer death.…”

Time pressure predicts decisional regret in men with localized prostate cancer: data from a longitudinal multicenter study

“…Experimental studies in other contexts have shown that time pressure is associated with less adherence to guidelines [14] and greater decisional regret [15]. Although lPCa often does not require immediate action, the word "cancer" alone may create a desire for rapid local treatment in many patients [16]. Given the resulting time pressure, it is a challenge to carefully discuss the respective side effects of all treatment options.…”

Psychological predictors of delayed active treatment following active surveillance for low‐risk prostate cancer: The Patient REported outcomes for Prostate cARE prospective cohort study

“…[17][18][19] Formal AS protocols include monitoring the cancer via periodic PSA tests, digital rectal exams, prostate biopsies, and MRI. 4,5,13,[20][21][22][23] Monitoring provides the option to undergo curative treatment and is based on evidence of disease progression and on patient and physician preferences. Several studies have shown that disease progression results in switching from AS to surgery or radiation.…”

“…Several studies have shown that disease progression results in switching from AS to surgery or radiation. 13 , 20 , 23 , 24 Among the few studies that have conducted a longitudinal assessment of the role of patient preferences and anxiety in switching to AT, there is evidence of discontinuing AS due to anxiety or personal preference and without evidence of disease progression. 23 , 24 , 25 However, not all studies have found strong evidence showing that PCa‐related anxiety results in being more likely to opt out of AS.…”