Multi-Level Factors Influencing Active Surveillance Initiation Among Elderly Medicare Beneficiaries Newly Diagnosed With Low-Risk and Favorable Intermediate-Risk Prostate Cancer: An Active Comparator New User Retrospective Cohort Study in the United...
Author(s)
Bernard Bright K. Davies-Teye, MD, MPH, PhD1, Eberechukwu Onukwugha, MSc, PhD1, M. Minhaj Siddiqui, MD, FACS2, Julia F. Slejko, MS, PhD1, Zafar Zafari, PhD1, C. Daniel Mullins, PhD1.
1Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA, 2University of Maryland School of Medicine, Baltimore, MD, USA.
1Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA, 2University of Maryland School of Medicine, Baltimore, MD, USA.
Presentation Documents
OBJECTIVES: Active surveillance (AS) is guideline-recommended strategy for managing low-risk and favorable intermediate-risk localized prostate cancer (LIPCa: cT1-cT2c, cN0, cM0, grade group (GG)≤2) due to its quality-of-life benefits and comparable survival to radical treatment (RT). However, AS uptake among elderly Medicare beneficiaries remains low and varies across neighborhoods, physicians, and practice contexts. This study quantified the associations between these factors and AS initiation.
METHODS: We conducted an active-comparator new-user retrospective cohort study using SEER-Medicare data (2006-2020) linked to PolicyMap's Census tract-level social determinants of health data. Incident LIPCa cases were identified using tumor-node-metastasis (TNM) staging and American Urological Association (AUA) risk stratification algorithms. AS initiation within 18 months of diagnosis was identified using validated algorithms; RT using procedure/ICD-9/10-CM codes. Subject-specific adjusted odds ratios (aORs; 95% confidence intervals [CIs]) and intraclass correlation coefficients for cluster levels, including physician level, were estimated using generalized linear mixed models. Sensitivity analyses evaluated a 12-month AS window and risk-stratified subgroups.
RESULTS: Among 14,728 patients, 20.7% initiated AS. AS was more likely among those aged ≥70 years (aOR=1.898, 95% CI=1.534-2.347), residing in the Western US (aOR=2.131, 95% CI=1.558-2.914), obese (aOR=1.543, 95% CI=1.088-2.188), or more recent years (2014-2015 vs. 2007-2009: aOR=5.437, 95% CI=3.524-8.389). Patients without confirmatory biopsy or MRI had higher odds of AS (aOR=1.762, 95% CI=1.389-2.236), while MRI-guided biopsy (aOR=0.605, 95% CI=0.447-0.818) and GG2 tumors (aOR=0.374, 95% CI=0.252-0.553) reduced AS use. AS was more likely among patients with ≥cT2 and CCI≥2 (aOR=3.135, 95% CI=1.445-6.800), tracts with moderate public transport access (aOR=1.439, 95% CI=1.028-2.014) or low-education older adults (aOR=2.069, 95% CI=1.026-4.170). High-volume physicians (aOR=16.184, 95% CI=11.859-22.084) and practices (aOR=1.590, 95% CI=1.229-2.056) were associated with higher AS odds; radiation oncologists and interventional radiologists had lower AS odds.
CONCLUSIONS: Among elderly Medicare beneficiaries with LIPCa, AS initiation was influenced by multilevel factors, with physician characteristics being the strongest determinants.
METHODS: We conducted an active-comparator new-user retrospective cohort study using SEER-Medicare data (2006-2020) linked to PolicyMap's Census tract-level social determinants of health data. Incident LIPCa cases were identified using tumor-node-metastasis (TNM) staging and American Urological Association (AUA) risk stratification algorithms. AS initiation within 18 months of diagnosis was identified using validated algorithms; RT using procedure/ICD-9/10-CM codes. Subject-specific adjusted odds ratios (aORs; 95% confidence intervals [CIs]) and intraclass correlation coefficients for cluster levels, including physician level, were estimated using generalized linear mixed models. Sensitivity analyses evaluated a 12-month AS window and risk-stratified subgroups.
RESULTS: Among 14,728 patients, 20.7% initiated AS. AS was more likely among those aged ≥70 years (aOR=1.898, 95% CI=1.534-2.347), residing in the Western US (aOR=2.131, 95% CI=1.558-2.914), obese (aOR=1.543, 95% CI=1.088-2.188), or more recent years (2014-2015 vs. 2007-2009: aOR=5.437, 95% CI=3.524-8.389). Patients without confirmatory biopsy or MRI had higher odds of AS (aOR=1.762, 95% CI=1.389-2.236), while MRI-guided biopsy (aOR=0.605, 95% CI=0.447-0.818) and GG2 tumors (aOR=0.374, 95% CI=0.252-0.553) reduced AS use. AS was more likely among patients with ≥cT2 and CCI≥2 (aOR=3.135, 95% CI=1.445-6.800), tracts with moderate public transport access (aOR=1.439, 95% CI=1.028-2.014) or low-education older adults (aOR=2.069, 95% CI=1.026-4.170). High-volume physicians (aOR=16.184, 95% CI=11.859-22.084) and practices (aOR=1.590, 95% CI=1.229-2.056) were associated with higher AS odds; radiation oncologists and interventional radiologists had lower AS odds.
CONCLUSIONS: Among elderly Medicare beneficiaries with LIPCa, AS initiation was influenced by multilevel factors, with physician characteristics being the strongest determinants.
Conference/Value in Health Info
2025-11, ISPOR Europe 2025, Glasgow, Scotland
Value in Health, Volume 28, Issue S2
Code
EPH167
Topic
Epidemiology & Public Health, Health Service Delivery & Process of Care, Study Approaches
Topic Subcategory
Safety & Pharmacoepidemiology
Disease
Oncology, Personalized & Precision Medicine, Reproductive & Sexual Health, Surgery