Page 22 - An Evidence Review of Active Surveillance in Men With Localized Prostate Cancer

Number of Cores
One study examined trends in the number of biopsy cores obtained during diagnostic
workup, and found that between 1997 and 2002 the average number of cores obtained per
patients had increased by 0.41 cores annually (from a mean of 7.5 to a mean of 9.8 cores per
patient).

Histopathologic Grading Changes
One study reported the results of regrading in 2002-04 pathology slides from patients
diagnosed in 1990-92. The regrading resulted in the assignment of significantly higher Gleason
scores compared to the original readings (mean score increase from 5.95 to 6.8).

Differences in Geographical Access and Other System-Level Factors
Four studies (covering 1986–2003) reported information on changes in the distribution of
patients by system-level factors. Among three studies on trends in the distribution of patients’
insurance status at diagnosis, the two CaPSURE analyses demonstrated a decrease in the
proportion of patients with Medicare coverage at the time of diagnosis over the time periods
covered (1997–2003 and 1989–2001). The POCS analysis did not demonstrate a change in the
distribution of insurance status over time (1998–2002). An analysis of POCS comparing 1998 to
2002 reported an increase over time in the number of patients residing in areas of higher median
income. Patterns in the distribution of income are difficult to interpret because sampling
strategies changed and different regions were included at the different time points. An analysis of
NCDB found little evidence of change in the distribution of patients by hospital caseload over
time (1986–87 and 1992).

Trends in Treatment Patterns

Among the 21 studies (covering 1973–2008) from which data could be gleaned regarding
treatment patterns over time, most demonstrated decreasing trends in the proportion of patients
being managed with observational strategies of no active treatment (AS, WW or expectant
management), with or without androgen deprivation therapy (ADT). In all seven studies
providing data since 2000, the proportion of patients receiving AS or WW was less than 10
percent; this also held true for the subgroups of patients with “low-risk disease” investigated in
two studies.

Key Question 2. How are active surveillance and other observational
management strategies defined?
The terms AS and WW (as well as others) have been used by investigators to denote
strategies both with and without curative intents. There is a broad spectrum of approaches for
observational strategies described in research publications. For the purpose of operationalizing
the process of summarizing the various definitions, we divided protocols into those clearly
described as having curative intent and those in which their aims were either unclear or primarily
palliative, regardless of how these regimens were labeled. This categorization was applied for
practical reasons, not to suggest what the definitions or protocols for AS, WW, or any other
observational strategy should be.

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