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Influence of Sociodemographic Factors on Definitive Intervention Among Very Low- and Low-Risk Active Surveillance Patients

  • Rashid Sayyid,
  • Laurence Klotz,
  • John Benton,
  • Joshua Lambert,
  • Phillip Woodruff,
  • Martha Terris,
  • Christopher Wallis,
  • Zachary Klaassen

Publication: Journal of Urology, September 2021

Introduction and objective

A substantial proportion of prostate cancer (PCa) patients on active surveillance (AS) undergo definitive treatment within ten years of diagnosis. Patient sociodemographic factors influencing decision to opt for definitive therapy, and, specifically, choice of radical prostatectomy (RP) versus radiation therapy (XRT) remain unclear. Our objective was to evaluate sociodemographic factors influencing the decision to undergo delayed treatment, and specifically the choice of RP versus XRT, following a period of AS.


The Surveillance, Epidemiology, and End Results (SEER) Prostate with Watchful Waiting database was used to identify patients diagnosed with NCCN low-risk PCa between 2010 and 2015, managed initially with AS for at least one year following diagnosis and subsequently underwent definitive therapy (RP or XRT). We sought to determine sociodemographic predictors both of undergoing definitive intervention regardless of modality and of RP versus XRT, using multivariable regression analyses controlling for oncologic characteristics.


32,874 patients were included. 21,255 (64.7%) patients underwent delayed treatment, with 3,751 (17.6%) and 17,463 (82.2%) opting for RP and XRT, respectively. Patients who were older at diagnosis (60-69 vs. 30-49 OR 1.33, p=0.007), diagnosed in the Southeast (OR 1.26, p<0.001) or Midwest (OR 1.22, p=0.021), and were of higher socioeconomic status (highest vs. lowest OR 1.67, p<0.001) were significantly more likely to undergo any definitive therapy. Men who were uninsured (OR 0.34, p<0.001), had Medicaid (OR 0.82, p=0.024), or were not married (OR 0.85, p<0.001) were less likely to undergo definitive treatment. With regards to choice of treatment, the following sociodemographic factors predicted decreased odds of choosing RP (i.e. higher odds of receiving XRT): older age at diagnosis (OR 0.038,p<0.001), African American race (OR 0.71, p=0.018), unmarried status (OR 0.53, p<0.001), and higher SES (OR 0.65, p=0.001). Hispanic race (OR 1.45, p=0.005) was associated with increased odds of choosing RP.


The majority of patients initially treated with AS for low risk PCa underwent delayed definitive treatment within five years of diagnosis. Sociodemographic factors including race, socioeconomic status, marital status, insurance status and region of residence were significantly associated with the likelihood of undergoing definitive therapy. The majority of these patients (82.2%) chose definitive XRT compared to only 17.6% for RP.

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