title: Who bears the greatest burden of aggressive treatment of indolent prostate cancer?
abstract: OBJECTIVE
  The long-term prostate cancer-specific survival for patients initially managed with active surveillance for low-risk prostate cancer ranges from 97% to 100%. We characterized factors that are associated with aggressive treatment with radical prostatectomy or radiation for indolent prostate cancer (defined as screening-detected, low-risk disease).
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results Program was used to extract a cohort of 39,803 men diagnosed with prostate-specific antigen-detected, low-risk prostate cancer (clinical category T1c, Gleason score ≤6, and prostate-specific antigen <10) from 2004 to 2010. After socioeconomic profiles were generated from county-linked education and income data, multivariable logistic regression was used to determine whether there were any factors associated with high rates of aggressive treatment.
  
  
  RESULTS
  The rate of aggressive treatment among all men with indolent prostate cancer was 64.3%. Greater rates of aggressive treatment were experienced by men with high socioeconomic status, Caucasian men, and married men (P < .001 for all cases). The increased adjusted odds for receipt of aggressive therapy were 1.25 (95% confidence interval [CI], 1.17-1.32; P < .001), 1.26 (95% CI, 1.21-1.32; P < .001), and 1.88 (95% CI, 1.80-1.97; P < .001) for men with high socioeconomic status, Caucasian men, and married men, respectively, compared with men with low socioeconomic status, non-Caucasian men, and unmarried men, respectively.
  
  
  CONCLUSIONS
  Although men with high socioeconomic status, Caucasian men, and married men often receive the highest quality health care and have the best outcomes for many cancers, it seems that they are most at risk for the avoidable potential harms of aggressive treatment of indolent prostate cancer. Future policy should encourage more stringent guidelines for deferred treatment and culturally and sociodemographically competent counseling of active surveillance.
authors: Harvard Medical School, Boston, Mass.
authors: Brandon A
authors: BA
authors: Mahal
authors: Departments of Urology and Epidemiology and Public Health, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, Calif.
authors: Matthew R
authors: MR
authors: Cooperberg
authors: Harvard Radiation Oncology Program, Boston, Mass.
authors: Ayal A
authors: AA
authors: Aizer
authors: Harvard Medical School, Boston, Mass.
authors: David R
authors: DR
authors: Ziehr
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Andrew S
authors: AS
authors: Hyatt
authors: Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Toni K
authors: TK
authors: Choueiri
authors: Department of Urology, UCLA Medical Center, Los Angeles, Calif.
authors: Jim C
authors: JC
authors: Hu
authors: Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Christopher J
authors: CJ
authors: Sweeney
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Clair J
authors: CJ
authors: Beard
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Anthony V
authors: AV
authors: D'Amico
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Neil E
authors: NE
authors: Martin
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Peter F
authors: PF
authors: Orio
authors: Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Quoc-Dien
authors: QD
authors: Trinh
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. Electronic address: pnguyen@LROC.harvard.edu.
authors: Paul L
authors: PL
authors: Nguyen
mesh_terms: D000368:Aged; D014408:Biomarkers, Tumor / Q000097:blood; D006801:Humans; D008297:Male; D017533:Marital Status; D008875:Middle Aged; D017430:Prostate-Specific Antigen / Q000097:blood*; D011468:Prostatectomy / Q000191:economics*; D011471:Prostatic Neoplasms / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D044469:Racial Groups; D018570:Risk Assessment; D012307:Risk Factors; D012959:Socioeconomic Factors
chemical_list: D014408:Biomarkers, Tumor; D017430:Prostate-Specific Antigen
keywords: Health policy; Low-risk; Overtreatment; Population health; Prostate-specific antigen; Prostatic neoplasms