Introduction: According to Dutch guidelines, active-surveillance (AS) is recommended for prostate cancer patients with the lowest risk of cancer progression. However, a proportion of these patients still undergo immediate treatment with curative intent (e.g. radical prostatectomy, external beam radiotherapy or brachytherapy). Variation in the uptake of AS between hospitals might be explained by heterogeneity in patient and tumour characteristics but also hospital-related factors may play a role. The aim of this study is to provide insight in the treatment variation of very-low-risk prostate cancer patients in the Netherlands and to assess the role of hospital-related factors.
Methods: All patients diagnosed with very-low-risk prostate cancer (cT1c-cT2a, PSA<10 ng/mL, Gleason score<7 and <3 positive cores) between Oct 2015 - Apr 15th 2016 were identified through the population-based Netherlands Cancer Registry. Multilevel logistic regression analyses were performed to examine the crude and case-mix adjusted probability of undergoing immediate treatment versus AS according to hospital of diagnosis and to evaluate the effect of hospital-related factors.
Results: In total 563 (87.0%) of the 647 patients who fulfilled the inclusion criteria for very-low-risk prostate cancer were managed with AS. The crude proportion of patients with AS varied from 50-100% between hospitals. After adjusting for patient and tumour characteristics, this range decreased to 67-97%. Multivariable multilevel logistic regression analyses showed that cT2a vs. cT1c (OR= 2.1, 95%CI:1.2-3.8), increasing PSA level at diagnosis (OR=1.2; 95%CI:1.0 – 1.4), two vs. one positive core (OR=2.7, 95%CI:1.6-4.6), diagnostic MRI (OR=2.7, 95%CI:1.4-5.1), discussion of a patient in a multidisciplinary team (OR=2.2, 95%CI:1.1-4.5) and discussion of treatment options with the patient (OR=2.9 95%CI:1.3-6.2) were all factors associated with immediate treatment. In addition, patients diagnosed in a non-academic referral hospital were less often treated immediately compared to patients diagnosed in a community hospital (OR=0.5, 95%CI:0.2-0.9).
Conclusion: The vast majority of Dutch very-low-risk prostate cancer patients are managed with AS but variation between hospitals exists. Part of the variation is explained by patient- and tumour characteristics but also hospital-related factors play a role. This implies that clinical practice could be improved.