Uptake of active surveillance for low-risk prostate cancer is very high in the Veterans Affairs (VA) health system, according to a research letter published online Aug. 13 in the Journal of the American Medical Association.
Grace Lee, M.D., from the San Francisco VA Medical Center, and colleagues evaluated the incidence and quality of active surveillance use in the national VA Healthcare System. The analysis included 73,042 eligible patients with diagnoses (2005 to 2024) of low- and favorable intermediate-risk prostate cancer.
The researchers found that 38,130 veterans (52 percent) were treated initially with active surveillance or watchful waiting. For patients with low-risk disease, rates of active surveillance use increased over time (27 to 93 percent), while rates increased from 14 to 61 percent for patients with favorable intermediate-risk disease. Across individual VA facilities, rates of active surveillance ranged from 23 to 93 percent. Older age (odds ratio [OR], 1.43 per decade) and more recent year of diagnosis (OR, 1.21 per year) were associated with increased odds of active surveillance. Decreased odds of active surveillance were seen for Black or African American race (OR, 0.95 versus White), Hispanic or Latino ethnicity (OR, 0.85 versus non-Hispanic), Gleason grade group 2 versus 1 (OR, 0.13), Area Deprivation Index score (OR, 0.97 per quartile), and greater percentage of positive-result biopsy cores (OR, 0.88 per decile).
“Prostate cancer care in the VA Healthcare System reflects the best uptake of active surveillance or watchful waiting for favorable-risk disease, suggesting veterans are receiving guideline-based management for favorable-risk prostate cancer,” the authors write.
Several authors disclosed ties to the pharmaceutical industry.
Active surveillance is intended to help specific patients avoid or delay unnecessary treatment and its potential harms. The VA setting may offer a particularly interesting model because patients are treated within an integrated healthcare system. Higher uptake of active surveillance may signal progress toward reducing overtreatment, but uptake alone doesn’t show whether it is applied consistently across racial or ethnic groups or whether outcomes remain equitable.
Black men continue to be disproportionately burdened by prostate cancer, facing higher incidence and mortality rates than any other racial or ethnic group in the United States. Yet Black men choose active surveillance less frequently than white men. And historically, worries about more aggressive underlying disease and unequal access to quality care can often drive clinicians and patients away from surveillance.
With this in mind, several clinical questions arise:
Before active surveillance is considered, clinicians must consider risk stratification to ensure that only patients with slow-growing, indolent disease avoid immediate treatment, while those harboring more aggressive cancers are identified earlier.
Clinicians can determine patient eligibility for active surveillance by assessing for the following:
Active surveillance should not be seen as “doing nothing.” It requires reliable monitoring and a healthcare infrastructure that allows patients to receive follow-up testing on schedule.
Even if a patient is an appropriate candidate for active surveillance, successful surveillance depends on consistent access to:
A patient, particularly Black male patients, cannot benefit from active surveillance if structural barriers make the “surveillance” component difficult to maintain.
High active surveillance rates represent progress in reducing overtreatment for low-risk prostate cancer. But for Black patients, who continue to experience disproportionate prostate cancer mortality, equity remains more than simply increasing or decreasing the use of surveillance. Clinicians must ensure that treatment decisions are based on accurate individual risk assessment, shared decision-making, and a realistic ability to maintain long-term follow-up.
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