48 Background: The incidence of stage IV prostate cancer in the United States has risen over the past decade, possibly reflecting changes in PSA screening guidelines. Recent studies have also shown increasing implementation of active surveillance in the initial management of intermediate-risk prostate cancer. However, the impact of these practice changes on trends in advanced disease remains unclear. We evaluated temporal trends in diagnosis, treatment, and survival among men with advanced-stage prostate cancer using the NCDB. Methods: The NCDB (2010–2021) was queried for demographics, comorbidities, PSA, Gleason score, stage, and treatment. Multivariable logistic regression assessed associations with stage IV diagnosis over time. Propensity score modeling balanced treatment (Tx) versus no treatment/active surveillance (nTx/AS) groups based on age, race, region, facility type, insurance, income, education, and PSA. Results: The overall NCDB cohort (n= 1424835), which included patients across all stages, comprised 79.8% White, 15.4% Black, and 4.9% Hispanic men. The median age at diagnosis was 66 years, with a median PSA of 4.4 ng/ml. After inverse probability weighting (IPW), overall survival (OS) was modestly improved in the nTx group compared to the Tx group (HR 0.96; 95% CI 0.93–0.99). However, among patients with stage III–IV disease, the nTx group had markedly worse OS compared with those who underwent Tx (HR, 2.45; 95% CI, 2.33–2.58). For men diagnosed with stage IV prostate cancer, multivariable logistic regression showed that the likelihood of presenting with metastatic disease increased significantly over time. The odds of a stage IV diagnosis rose from 2011 (OR 1.03; 95% CI 1.00–1.07) to 2021 (OR 2.48; 95% CI 2.41–2.56; p < 0.001). Subgroup analysis of men with stage IV prostate cancer found that 77.4% were White, 17.4% Black, and 6.5% Hispanic, with a median age of 69 years and PSA 42.8 ng/mL. Those managed with nTx/AS were older (78 vs 69 years), had higher PSAs (95.7 vs 41.2 ng/mL), were less often treated at research and academic centers (26% vs 40%), and more frequently insured by Medicare (71% vs 56%). Conclusions: The proportion of stage IV prostate cancer diagnoses has significantly increased over the past decade. Among men with advanced-stage (III–IV) disease, OS was significantly improved in those who received active treatment, underscoring the importance of assessing factors that influence withholding treatment. Untreated patients were older, had higher PSA, and were less often managed at academic or research hospitals.
Linville et al. (Sun,) studied this question.