Psychological predictors of delayed active treatment following active surveillance for low‐risk prostate cancer: The Patient REported outcomes for Prostate cARE prospective cohort study

OBJECTIVES: In a prospective, comparative effectiveness study, we assessed clinical and psychological factors associated with switching from active surveillance (AS) to active treatment (AT) among low‐risk prostate cancer (PCa) patients. METHODS: Using ultra‐rapid case identification, we conducted pretreatment telephone interviews (N = 1139) with low‐risk patients (PSA ≤ 10, Gleason≤6) and follow‐up interviews 6–10 months post‐diagnosis (N = 1057). Among men remaining on AS for at least 12 months (N = 601), we compared those who continued on AS (N = 515) versus men who underwent delayed AT (N = 86) between 13 and 24 months, using Cox proportional hazards models. RESULTS: Delayed AT was predicted by time dependent PSA levels (≥10 vs. <10; HR = 5.6, 95% CI 2.4–13.1) and Gleason scores (≥7 vs. ≤6; adjusted HR = 20.2, 95% CI 12.2–33.4). Further, delayed AT was more likely among men whose urologist initially recommended AT (HR = 2.13, 95% CI 1.07–4.22), for whom tumour removal was very important (HR = 2.18, 95% CI 1.35–3.52), and who reported greater worry about not detecting disease progression early (HR = 1.67, 1.05–2.65). In exploratory analyses, 31% (27/86) switched to AT without evidence of progression, while 4.7% (24/515) remained on AS with evidence of progression. CONCLUSIONS: After adjusting for clinical evidence of disease progression over the first year post‐diagnosis, we found that urologists' initial treatment recommendation and patients' early treatment preferences and concerns about AS each independently predicted undergoing delayed AT during the second year post‐diagnosis. These findings, along with almost one‐half undergoing delayed AT without evidence of progression, suggest the need for greater decision support to remain on AS when it is clinically indicated.