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Platinum Priority – Editorial

Referring to the article published on pp. 729–737 of this issue

Patterns of Care for Prostate Cancer Patients: Predictors of Care,

But For Whom?

Stephen B. Williams

a ,

Brian F. Chapin

b , *


Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA;


Department of Urology, The University of Texas

MD Anderson Cancer Center, Houston, TX, USA

Preferred treatment options for localized prostate cancer

include active surveillance for patients with low-risk

disease, with surgery and radiation therapies reserved for

intermediate-risk and high-risk disease


. Aside from

tumor characteristics, determinants such as age, race/

ethnicity, socioeconomic status, and insurance have impli-

cations for the treatments administered


. In this issue


European Urology

, Gray et al


present temporal trends

in prostate cancer care using the National Cancer Database

to identify trends in care and predictors of receipt of

prostate cancer care. Specifically, the authors examined

temporal effects of race/ethnicity, insurance, and socioeco-

nomic status on treatment type during the study period.

They differentiated observation versus treatment (radical

prostatectomy [RP], brachytherapy, or external-beam

radiotherapy) according to the National Comprehensive

Cancer Network guideline on stratification for disease risk.

While the authors should be commended for critically

evaluating determinants for observation versus treatment

according to disease risk, there are a few to discuss. First, the

use of observation for clinically localized prostate cancer is

not guideline-recommended for low-risk prostate cancer. In

the present analysis, patients in the observation category

probably include those who may be on watchful waiting or

active surveillance. It should be cautioned that there

remains a distinct difference between watchful waiting

and active surveillance, since the latter entails detailed

monitored follow-up, with treatment initiated at set

determinants. Furthermore, active surveillance has been

recommended for men diagnosed with low-risk prostate



. However, the incidence of overtreatment of

low-risk disease is well known and still prevalent, as

depicted in this study, with trends for greater RP utilization

for low-risk disease


. In addition to determining

predictors of increased utilization of active surveillance

for indolent prostate cancer, the quality of surveillance has

also been questioned

[9,10] .

Similar to the present study,

previous research using SEER-Medicare linked data

revealed significantly lower utilization of watchful wait-

ing/active surveillance


. Moreover, in another study

evaluating the quality of active surveillance, when compar-

ing patients undergoing active treatment, those who

underwent watchful waiting/active surveillance were less

likely to undergo prostate-specific antigen testing and

attend office visits within the 2 yr following diagnosis





[12] .

Of the 3656 patients undergoing watchful

waiting/active surveillance, only 166 (4.5%) were on ‘‘active

surveillance’’ (according to the a priori definition). This

means that the current utilization of observation for low-

risk patients reported in the present study as 21.3% at best

does not accurately represent active surveillance utilization

patterns; it is likely that utilization is far less and under-

determined from the present data set.

Interestingly, RP utilization increased independent of

risk stratification, a surrogate for tumor biology. Further-

more, RP use increased in patients with high-risk disease

during the study period, when historically radiation with

androgen deprivation therapy was largely administered.

With the introduction of robotic prostatectomy and further

data supporting the utility of surgery as the initial step in

therapy among patients with high-risk disease, these

findings may not be surprising. However, even patients

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 7 3 8 – 7 3 9

available at


journal homepage:

DOI of original article:


* Corresponding author. Department of Urology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.

Tel. +1 713 7923250; Fax: +1 713 7944824.

E-mail address:

(B.F. Chapin).



2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.