The disparity of strategies for low-risk prostate cancer by facility type using a multi-institutional Japan-wide database

The disparity of strategies for low-risk prostate cancer by facility type using a multi-institutional Japan-wide database | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The disparity of strategies for low-risk prostate cancer by facility type using a multi-institutional Japan-wide database Satoshi Kobayashi, Masaki Shiota, Mizuki Onozawa, Satoru Taguchi, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6641831/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: There is an urgent need for more systematic investigations into how imaging inspection and primary treatment for low-risk prostate cancer vary by type of medical institution. To investigate disparities in imaging inspections and first-line treatment depending on the type of medical institution for low-risk prostate cancer using the Japan Study Group of Prostate Cancer database. Methods: Data on patients with low-risk prostate cancer diagnosed between 2016 and 2018 from a nationwide database of the Japan Study Group of Prostate Cancer were used. Among these databases, patient and tumor characteristics, image inspections for diagnosis, and first-line treatment at clinics, community hospitals, and university hospitals were compared statistically. Results: This analysis included patients with low-risk prostate cancer at clinics (n = 89), community hospitals (n = 1259), and university hospitals (n = 671). The three facilities had no significant differences in the performance of computed tomography scans, bone scintigraphy, and magnetic resonance imaging scans. Active surveillance was less performed in clinics and university hospitals, compared with community hospitals. Androgen deprivation therapy was significantly more common, but curative treatments, including radiation and prostatectomy, were less performed in clinics. Curative radiation was significantly more common, but androgen deprivation therapy was less performed in university hospitals. Conclusions: Our study analyzed data on low-risk prostate cancer obtained from a Japanese multi-institutional registry and showed differences in first-line treatment options by type of medical institution. prostate cancer low risk active surveillance prostatectomy Introduction Prostate cancer is one of the most common cancers in men, especially in the older patients [ 1 ]. With the widespread use of prostate-specific antigen (PSA) testing, the number of cases diagnosed early has increased, and the number of patients with low-risk prostate cancer, in particular, is on the rise [ 2 ]. Low-risk prostate cancer progresses slowly and often does not require aggressive treatment, so it is necessary to perform appropriate diagnosis and risk assessment while avoiding overdiagnosis and overtreatment [ 3 ]. Selecting an appropriate diagnostic method at the initial examination is important in improving patient prognosis and allocating medical resources appropriately [ 4 ]. However, there may be differences in testing methods and diagnostic approaches depending on the type of medical institution, underscoring the potential benefits of a more standardized and universally applicable approach to prostate cancer diagnosis [ 5 ]. In the diagnosis of prostate cancer, PSA testing, digital rectal examination, and transrectal ultrasound-guided biopsy have traditionally been used as standard methods [ 6 ]. However, these methods have limitations, and the risk of complications due to excessive biopsies and the psychological burden on patients are issues, especially in the diagnosis of low-risk prostate cancer [ 7 ]. Therefore, with the advancement of imaging diagnostic technology, more accurate non-invasive diagnostic methods have attracted attention in recent years [ 8 ]. Multiparametric magnetic resonance imaging (mpMRI) is becoming widely adopted as a promising diagnostic method because it can comprehensively evaluate prostate cancer's structural and functional information [ 9 ]. In particular, it has been reported that risk assessment using the Prostate Imaging-Reporting and Data System score is possible and is helpful as an indicator for appropriately determining the suitability of biopsy in low-risk patients [ 10 ]. Ultrasound imaging also plays an important role in the diagnosis of prostate cancer. Conventional transrectal ultrasound is widely used to evaluate the morphology of the prostate but has limited ability to identify cancer [ 11 ]. In addition, bone scintigraphy and computed tomography (CT) scans may be performed to confirm the presence or absence of metastasis when diagnosing prostate cancer. However, the introduction of these diagnostic technologies may vary depending on the medical institution's size, facilities, and personnel structure [ 12 ]. University hospitals are well equipped with advanced imaging diagnostic equipment and specialists; in many cases, mpMRI diagnoses are performed as standard [ 13 ]. On the other hand, while CT and mpMRI can be performed at community hospitals, post-diagnosis treatment options are limited due to the facility environment [ 14 ]. Furthermore, in clinics, it is common to focus on PSA and ultrasound tests at the early stage of diagnosis and refer patients to higher-level medical institutions as necessary. As such, there is an urgent need for more systematic investigations of the actual situation, especially regarding the differences in the testing methods and diagnostic strategies at the first consultation depending on the type of medical institution. This study aims to investigate the differences in image inspection and strategy of first-line treatment at the first consultation for low-risk prostate cancer patients between clinics, community hospitals, and university hospitals. Materials and Methods Statement of ethics All procedures in this study followed the 1964 Declaration of Helsinki according to the Strengthening the Reporting of Observational Studies in Epidemiology statement [ 15 ]. The study protocol was reviewed and approved by each Institutional Review Board. Moreover, informed consent was obtained from all of the patients, and they were provided with clear opportunities to opt out, respecting their autonomy and right to choose. Patient eligibility Anonymized data of patients (almost all patients were Japanese) who were diagnosed low-risk prostate cancer, defined as PSA ≤ 10, Gleason score ≤ 6, and stage T1a-c/T2a, between 2016 and 2018 were obtained from a Japanese multicenter registry established by J-CaP. The cases (n = 4) diagnosed with non-adenocarcinoma were excluded. Of the 16,623 patients, a total of 2,019 patients with low-risk prostate cancer were enrolled in this cohort study. A clinic was defined as a medical institution with 19 or fewer inpatient beds or no inpatient facilities, a community hospital was defined as a medical institution with 20 or more inpatient beds, and a university hospital was defined as a hospital established as a facility necessary for education and research for university medical and dental schools that train doctors and dentists. Patients’ age, body mass index (BMI), PSA values, medical history, Gleason score, T stage, image inspection (CT scan, mpMRI scan, bone scintigraphy, Positron Emission Tomography (PET)-CT) and first-line treatment were all reviewed. The method of androgen deprivation therapy (ADT) was categorized as combined androgen blockade, castration monotherapy (surgical or medical castration) and others, including anti-androgen monotherapy, as described previously. This study retrospectively investigated the frequency of selection of active surveillance (AS)/watchful waiting (WW), ADT, curative radiotherapy, prostatectomy, and others (including docetaxel) as first-line treatments at each facility. Statistical analyses Continuous data, such as patient and tumor characteristics, are presented as median values with interquartile ranges (IQR). Categorical data are presented as counts and analyzed using Fisher’s exact test. Data with a normal distribution and a P-value of ≥ 0.05 in the Shapiro–Wilk test were analyzed using a t-test. In contrast, non-normally distributed data with a P-value of < 0.05 were analyzed using the Wilcoxon test. Tukey’s test was performed to compare the three group. All analyses used the JMP Pro version 18.0.0 for Mac (SAS. Institute Inc., Cary, NC, U.S.A.). The threshold for statistical significance was set at P < 0.05, and all P-values were two-tailed. To provide a comprehensive understanding of the factors influencing the decision-making for image inspections and first-line treatment for low-risk prostate cancer, a multivariable analysis was performed. This analysis set up with the community hospital as the control group and included factors as below: age, PSA value, T stage, and facility. Results Patients’ characteristics Table 1 showed a summary of the patient’s background characteristics. Patients’ age was different among clinic, community hospital and university hospital; elder in clinic and younger in university hospital. (clinic vs. community hospital, community hospital vs. university hospital, clinic vs. university hospital: p = 0.002, p = 0.002, P < 0.001 for each). No significant differences were observed between facilities regarding BMI, or medical history (hypertension, heart disease, hyperlipidemia, diabetes mellitus, pulmonary disease, gastric ulcer, and renal disease). Table 1 Baseline Patient Demographics in three clinical locations (IQR) Clinic Community hospital University hospital n = 89 n = 1259 n = 671 Age, years 72 (68–76) 70 (65–75) 68 (64–73) < 70 27 (31.4) 578 (45.9) 367 (54.7) 70–74 32 (36.0) 360 (28.6) 190 (28.3) 75–79 16 (18.0) 242 (19.2) 83 (12.3) ≦ 80 14 (15.7) 79 (6.27) 114 (17.0) BMI, kg/m 2 23.3 (21.9–25.2) 23.7 (21.8–25.5) 23.7 (22.0–25.5) Hypertension, % 36 (40.5) 581 (46.2) 282 (42.0) Heart disease, % 4 (4.49) 35 (2.78) 30 (4.47) Hyper lipidemia, % 18 (20.2) 214 (17.0) 131 (19.5) Diabetes mellitus, % 17 (19.1) 173 (13.7) 93 (13.9) Pulmonary disease, % 0 (0) 34 (2.70) 12 (1.79) Gastric ulcer, % 4 (4.49) 38 (3.02) 27 (4.02) Renal disease, % 3 (3.37) 32 (2.54) 14 (2.09) BMI ; body mass index, IQR; interquartile range, PSA ; prostate specific antigen Prostate cancer’s characteristics Table 2 showed the result of cancer characteristics in this study. There were no significant differences in the Gleason score, total number of biopsy cores, or positive cores among the facilities. In terms of the TNM classification, the T stage was mostly T1c (74.1%) in clinics, while T2a was more frequently diagnosed in community hospital (34.9%), and furthermore in university hospital (41.9%). Table 2 Baseline prostate cancer characteristics (IQR) Clinic Community hospital University hospital n = 89 n = 1259 n = 671 PSA, ng/mL 5.58 (4.46–7.06) 5.68 (4.68–7.20) 5.93 (4.79–7.62) Total Gleason score < 6, n (%) 0 (0) 12 (0.9) 7 (0.1) 6, n (%) 89 (100) 1247 (99.1) 664 (99.0) Total cores 12 (12–14) 12 (11–12) 12 (10–14) Number of positive cores 1 (1–2) 1 (1–3) 2 (2–3) T stage, (%) T1a 3 (3.4) 38 (3.02) 4 (0.60) T1b 4 (4.5) 10 (0.79) 0 (0.00) T1c 66 (74.1) 772 (61.3) 386 (57.5) T2a 16 (18.0) 439 (34.9) 281 (41.9) IQR; interquartile range Image inspection for low-risk prostate cancer The results of image examinations for staging performed on patients diagnosed with prostate cancer by prostate biopsy were shown in Table 3. The frequencies of CT scan were 46.1%, 89.8% and 87.2% in clinic, community hospital and university hospital, respectively (Table 3). MRI were performed in 59.6%, 64.5% and 85.0% of patients in clinic, community hospital and university hospital, respectively (Table 3). Bone scintigraphy were performed in 41.6%, 77.7% and 82.7% of patients in clinic, community hospital and university hospital, respectively (Table 3). Table 3 Detection and staging for prostate cancer Clinic Community hospital University hospital n = 89 n = 1259 n = 671 CT scan, % 41 (46.1) 1131 (89.8) 585 (87.2) Multiparametric MRI scan, % 53 (59.6) 812 (64. 5) 570 (85.0) Bone scintigraphy, % 37 (41.6) 978 (77.7) 555 (82.7) PET CT scan, % 34 (38.2) 15 (1.19) 6 (0.89) CT ; computed tomography, MRI ; Magnetic Resonance Imaging, PET ; Positron Emission Tomography. The results of the multivariate analysis were shown in Table 4 about image inspections. Performing CT and MRI scans was negatively associated with the T2 stage (p < 0.001 for each). On the other hand, age, PSA values, pathological outcomes, and institution did not show a relationship with the decision to undergo image inspections. Table 4 Multivariable analysis on association between image inspections. CT scan MRI scan Bone scintigraphy PET CT scan OR 95% CI P value OR 95% CI P value OR 95% CI P value OR 95% CI P value Age, years < 70 Ref – – Ref – – Ref – – Ref – – ≥ 70 1.27 0.285–5.69 0.752 < 0.001 0.00–0.00 0.980 1.00 0.00–0.00 1.00 < 0.001 0.00–0.00 0.989 PSA values, ng/dL < 4 Ref – – Ref – – Ref – – Ref – – ≥ 4 1.93 0.620–5.69 0.256 0.992 0.00–0.00 1.00 1.03 0.00–0.00 1.00 0.699 0.146–3.35 0.653 T stage T1 Ref – – Ref – – Ref – – Ref – – T2 0.023 0.006–0.092 < 0.001 * 0.262 0.187–0.368 < 0.001 * < 0.001 0.00–0.00 0.991 < 0.001 0.00–0.00 0.989 Institution Clinic 0.877 0.407–1.89 0.737 1.11 0.547–2.25 0.774 1.38 0.532–3.01 0.419 1.80 0.608–5.33 0.288 Community hospital Ref – – Ref – – Ref – – Ref – – University hospital 0.747 0.553–1.01 0.057 1.19 0.885–1.59 0.253 0.838 0.632–3.01 0.263 0.699 0.381–5.33 0.249 CI; confidence interval, CT ; computed tomography, OR ; odds rate, MRI ; magnetic resonance imaging, PET ; positron emission tomography, PSA ; prostate–specific antigen, * Statistically significant (P < 0.05) First-line treatment for low-risk prostate cancer Table 5 showed a result of the treatment strategy for low-risk prostate cancer in each institution. AS was chosen for 34.8%, 46.2% and 33.5% of patients with low-risk prostate cancer in clinic, community hospital and university hospital, respectively (Table 5). ADT was performed in 42.7%, 8.66% and 3.28% of patients with low-risk prostate cancer in clinic, community hospital and university hospital, respectively (Table 5). The frequencies of curative radiation were 2.25%, 13.6% and 28.0% in clinic, community hospital and university hospital, respectively (Table 5). The frequencies of prostatectomy were 12.4%, 29.4% and 34.9% in clinic, community hospital and university hospital, respectively (Table 5).The results of the multivariate analysis about first-line treatment for low-risk prostate cancer were shown in Table 6. High PSA value was significantly associated less likely with AS (odds ratio [OR], 0.650; p = 0.014) and androgen deprivation therapy (OR, 0.443; p = 0.001), but more likely with prostatectomy (OR, 3.79; p < 0.001). Also, T2 stage was significantly associated less likely with androgen deprivation therapy (OR, 0.302; p < 0.001). Regarding institutions, clinics (OR, 0.592; p = 0.023) and university hospitals (OR, 0.590; p < 0.001) were significantly associated with less choice of AS/WW. The use of ADT was more frequent in clinic (OR, 7.93; p < 0.001), but less frequent in university hospital (OR, 0.398; p < 0.001). Curative radiation was chosen less frequently in clinic (OR, 0.146; p = 0.008), but more frequently in university hospital (OR, 2.43; p < 0.001). Similarly, prostatectomy was chosen less frequently in clinic (OR, 0.356; p = 0.002). Table 5 Fist-line treatment for prostate cancer Clinic Community hospital University hospital n = 89 n = 1259 n = 671 Active surveillance/watchful waiting, % 31 (34.8) 587 (46.2) 225 (33.5) Androgen deprivation therapy, % 38 (42.7) 109 (8.66) 22 (3.28) Curative radiation, % 2 (2.25) 171 (13.6) 188 (28.0) Prostatectomy, % 11 (12.4) 370 (29.4) 234 (34.9) Others, % 7 (7.87) 22 (1.75) 2 (0.30) Table 6 Multivariable analysis on association between first line treatments for low–risk prostate cancer. Active surveillance/watchful waiting Androgen deprivation therapy Curative radiation Prostatectomy OR 95% CI P value OR 95% CI P value OR 95% CI P value OR 95% CI P value Age < 70 Ref – – Ref – – Ref – – Ref – – ≥ 70 0.846 0.610–1.17 0.317 1.17 0.687–1.98 0.565 1.14 0.745–1.74 0.552 1.11 0.787–1.56 0.553 PSA values, ng/dL < 4 Ref – – Ref – – Ref – – Ref – – ≥ 4 0.650 0.460–0.917 0.014 * 0.443 0.277–0.710 0.001 * 0.992 0.611–1.61 0.973 3.79 2.18–6.58 < 0.001 * T stage T1 Ref – – Ref – – Ref – – Ref – – T2 1.06 0.760–1.49 0.720 0.302 0.169–0.565 < 0.001 * 1.07 0.698–1.64 0.757 1.14 0.805–1.62 0.460 Institution Clinic 0.592 0.376–0.930 0.023 * 7.93 4.89–12.9 < 0.001 * 0.146 0.036–0.600 0.008 * 0.356 0.186–0.681 0.002 * Community hospital Ref – – Ref – – Ref – – Ref – – University hospital 0.590 0.485–0.718 < 0.001 * 0.398 0.248–0.638 < 0.001 * 2.43 1.92–3.08 < 0.001 * 1.22 0.999–1.50 0.051 CI; confidence interval, OR ; odds rate, PSA ; prostate–specific antigen, * Statistically significant (P < 0.05) Discussions In this study, we used a multi-institutional Japan-wide database to investigate image inspection for staging after diagnosis and the subsequent treatment status of patients with low-risk prostate cancer. Although our analysis showed no difference in the type of image inspection selected by institution, there were differences in first-line treatment by institution. This analysis suggests that elucidating the actual treatment status of low-risk prostate cancer may contribute to correcting the treatment disparity by institution. AS is considered an important option in the management of low-risk prostate cancer [ 18 ]. This AS has emerged as a management approach for prostate cancer with a good prognosis in response to the overtreatment of low-grade disease caused by the introduction of PSA screening. By monitoring with PSA values, regular prostate biopsies, and mpMRI, definitive treatment can be postponed until signs of cancer progression appear or avoided entirely if progression is not detected, and it is expected to reduce common side effects associated with treatment [ 19 ]. Newcomb et al. demonstrated that 10 years after diagnosis, approximately half of the men undergoing AS for favorable prostate cancer have progressed or are not treated, less than 2% have developed metastatic disease, and less than 1% have died of disease.[ 20 ] This report implied that men who were treated immediately after the first biopsy after diagnosis had similar long-term clinical outcomes of adverse pathological outcomes, recurrence, or metastasis to those who were treated after several years of surveillance. In a cohort study of AS in the Japanese population, approximately 30% of patients had pathological reclassification during biopsy, but the acceptance rate of biopsy declined over time, and six patients had metastases and one patient died of prostate cancer [ 21 ]. As a result, AS is becoming established as an option for low-risk prostate cancer in Japan [ 22 ]. Radiation therapy is also an option, and Lee et al. reported that in men with low-risk prostate cancer, 70 Gy in 28 fractions over 5.6 weeks had equivalent outcomes to 73.8 Gy in 41 fractions over 8.2 weeks [ 23 ]. Furthermore, the results of the PACE-B trial showed that five-fraction stereotactic body radiotherapy was a potent and feasible alternative to moderately fractionated radiotherapy for prostate cancer, providing similar efficacy and improved patient convenience [ 24 ]. A 15-year follow-up study of localized prostate cancer by Hamdy et al. showed that there was no significant difference in prostate cancer mortality among the three treatments of AS, surgery, and radiotherapy, suggesting that AS is an appropriate option, especially for low-risk patients with a life expectancy of more than 10 years [ 25 ]. While, in low-risk patients with a life expectancy of below 10 years, observation is recommended [ 26 ]. In this study, AS/WW was chosen in less than 35% of patients, suggesting an insufficient implementation of AS/WW for low-risk prostate cancer. However, Similar data that AS was chosen in 37% of low-risk prostate cancer between 2016 and 2018 in the United States was reported [ 27 ]. These findings suggest that low implementation of AS is a global issue although AS implementation rate rapidly increased to 60% in 2021 [ 27 ]. This study revealed less choice of AS/WW and curative treatment, but overuse of ADT in clinic. Less use of curative treatment may be influenced by higher age of patients in clinics. However, less use of AS/WW and overuse of ADT is not justified by higher age because those options may be harmful due to its adverse effect with less clinical benefit for low-risk prostate cancer. While curative treatment instead of AS/WW was chose more frequently in university hospital, which may be due to younger age, higher PSA level and higher T-stage in university hospital. Our study had several limitations. This study was conducted at multiple facilities in Japan, which may lead to heterogeneity in patient treatment and monitoring. Furthermore, this study did not include long-term treatment outcomes of therapeutic interventions. Therefore, further investigation of the effectiveness of each treatment option for low-risk prostate cancer was required. Finally, the patients who participated in this study were from Japan, and the application of these findings to other races, and regions, may be limited. Despite these limitations, this study analyzed the approach and treatment strategy for low-risk prostate cancer by type of medical institution in Japan, and the results showed that the difference in type significantly affects the treatment strategy for low-risk prostate cancer. Conclusion Our study analyzed data on low-risk prostate cancer obtained from a Japanese multi-institutional registry and found no differences in diagnostic image examinations by type of medical institution but did find differences in first-line treatment options by type of medical institution. The findings indicated a disparity of strategies for low-risk prostate cancer by facility type; less use of AS/WW and curative treatment, but an overuse of ADT in clinics while less use of AS/WW and ADT, but an overuse of curative treatment in university hospital for low-risk prostate cancer in Japan, suggesting an insufficient implementation of AS/WW in clinics and university hospital, and overuse of ADT in clinics. Abbreviations ADT; androgen deprivation therapy AS; active surveillance CT; computed tomography IQR; interquartile ranges mpMRI; multiparametric magnetic resonance imaging PET; positron emission tomography PSA; prostate-specific antigen WW; watchful waiting Declarations Author contribution All authors contributed to resources, and writing–review and editing. S.K. contributed to formal analysis, investigation, visualization, and writing–original draft. M.S. contributed to conceptualization. M.O. contributed to administration. H.K. contributed to supervision. Acknowledgment We thank all the patients whose data were analyzed in this study and all investigators involved. We appreciate the excellent support from Ms. Tae Nakano. Research involving human participants and / or animals: Not applicable. Data availability The data that support this study’s findings are available from the corresponding author [Satoshi Kobayashi], upon reasonable request. 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New England Journal of Medicine , 391 (15), 1413-1425. doi: 10.1056/NEJMoa2403365. Hamdy, F. C., Donovan, J. L., Lane, J. A., Metcalfe, C., Davis, M., Turner, E. L., ... & Neal, D. E. (2023). Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. New England Journal of Medicine , 388 (17), 1547-1558. doi: 10.1056/NEJMoa2214122. Gallagher, K. M., Christopher, E., Cameron, A. J., Little, S., Innes, A., Davis, G., ... & McNeill, A. (2019). Four‐year outcomes from a multiparametric magnetic resonance imaging (MRI)‐based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies. Bju International , 123 (3), 429-438. doi: 10.1111/bju.14513. Cooperberg, M. R., Meeks, W., Fang, R., Gaylis, F. D., Catalona, W. J., & Makarov, D. V. (2023). Time trends and variation in the use of active surveillance for management of low-risk prostate cancer in the US. JAMA network open , 6 (3), e231439-e231439. doi: 10.1001/jamanetworkopen.2023.1439. doi: 10.1001/jamanetworkopen. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6641831","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486719400,"identity":"76d82444-25de-45a0-932a-c41018428a9c","order_by":0,"name":"Satoshi Kobayashi","email":"","orcid":"","institution":"Kyushu University","correspondingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Kobayashi","suffix":""},{"id":486719401,"identity":"7d07454a-035b-47a0-9a9d-3d2d1e937270","order_by":1,"name":"Masaki Shiota","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABVUlEQVRIie2RMUvDQBTH31E4l6jrFSH9ClcyWFCaD+JyoWCXHh0EyVCkUoiL1PWkol8hwcntSqBdrF1vcEjo6FIQioMUk2ibpqW4CuYHB8fj/bj/uweQk/MXIai9uBaAAdHwThuSGl3U045UkalS0fc0+ZsSnaUCYBs6YWvKGqVe53IybcHJ/o0/oQEQyym+MXTr+OYhYZhAqwqFXuYZ+trvUDkALtSpwVisHHAXeY5vPYlYGdQA3cmMEvUQiYG3FRhyqYSOz6hqzgjgaDLBMsFErMyBP4yH799KcZQoJlXxK/MNBVSk9B3grmwkwQxMdpNgyI0V5GwoVFkdOuoS7qnGGWWU6Fjjbl+81C33OShUrG5NW5ulJOphYM+O+f14+Fj8sC+00tXIC6/Pj0w6ZEhNZ1W9nP2xle1AuguJ8E8hiqSVxZYNZflcTUK2tuXk5OT8C74AX2d+l7+3f9YAAAAASUVORK5CYII=","orcid":"","institution":"Kyushu University","correspondingAuthor":true,"prefix":"","firstName":"Masaki","middleName":"","lastName":"Shiota","suffix":""},{"id":486719402,"identity":"ce0d06c1-f179-4404-8b1d-3a2a2497f0e4","order_by":2,"name":"Mizuki Onozawa","email":"","orcid":"","institution":"International University of Health and Welfare Narita Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mizuki","middleName":"","lastName":"Onozawa","suffix":""},{"id":486719403,"identity":"a0dfd589-bb47-4017-bcb8-f0d7c236591a","order_by":3,"name":"Satoru Taguchi","email":"","orcid":"","institution":"The University of Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Satoru","middleName":"","lastName":"Taguchi","suffix":""},{"id":486719404,"identity":"2bb97027-2084-4737-ab78-cda7f91af106","order_by":4,"name":"Yoshiyuki Yamamoto","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Yoshiyuki","middleName":"","lastName":"Yamamoto","suffix":""},{"id":486719405,"identity":"ca8e9bd2-b12e-49b0-bda5-ec3cd90f568b","order_by":5,"name":"Shinichi Sakamoto","email":"","orcid":"","institution":"Chiba University","correspondingAuthor":false,"prefix":"","firstName":"Shinichi","middleName":"","lastName":"Sakamoto","suffix":""},{"id":486719406,"identity":"f4b78490-766b-45f7-9a17-110f94f63b37","order_by":6,"name":"Taketo Kawai","email":"","orcid":"","institution":"International University of Health and Welfare Ichikawa Hospital","correspondingAuthor":false,"prefix":"","firstName":"Taketo","middleName":"","lastName":"Kawai","suffix":""},{"id":486719407,"identity":"a8aae67e-d88e-4c37-b7b5-97a9252f8c1f","order_by":7,"name":"Tohru Nakagawa","email":"","orcid":"","institution":"Teikyo University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tohru","middleName":"","lastName":"Nakagawa","suffix":""},{"id":486719408,"identity":"5ffd7331-b74f-4806-9f43-74a21094793c","order_by":8,"name":"Shiro Hinotsu","email":"","orcid":"","institution":"Sapporo Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shiro","middleName":"","lastName":"Hinotsu","suffix":""},{"id":486719409,"identity":"ba654bf0-8e50-410d-8498-d5b5d493a8fd","order_by":9,"name":"Masatoshi Eto","email":"","orcid":"","institution":"Kyushu University","correspondingAuthor":false,"prefix":"","firstName":"Masatoshi","middleName":"","lastName":"Eto","suffix":""},{"id":486719412,"identity":"989de6dc-9234-4ae5-8b2a-0409cb34e881","order_by":10,"name":"Haruki Kume","email":"","orcid":"","institution":"The University of Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Haruki","middleName":"","lastName":"Kume","suffix":""}],"badges":[],"createdAt":"2025-05-12 00:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6641831/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6641831/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87890843,"identity":"e6c75524-b11a-41a5-a2c9-ffb3497f5a68","added_by":"auto","created_at":"2025-07-30 06:31:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":976877,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6641831/v1/3725676a-21b1-43c5-902e-29de991d7983.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The disparity of strategies for low-risk prostate cancer by facility type using a multi-institutional Japan-wide database","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProstate cancer is one of the most common cancers in men, especially in the older patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With the widespread use of prostate-specific antigen (PSA) testing, the number of cases diagnosed early has increased, and the number of patients with low-risk prostate cancer, in particular, is on the rise [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Low-risk prostate cancer progresses slowly and often does not require aggressive treatment, so it is necessary to perform appropriate diagnosis and risk assessment while avoiding overdiagnosis and overtreatment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Selecting an appropriate diagnostic method at the initial examination is important in improving patient prognosis and allocating medical resources appropriately [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, there may be differences in testing methods and diagnostic approaches depending on the type of medical institution, underscoring the potential benefits of a more standardized and universally applicable approach to prostate cancer diagnosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the diagnosis of prostate cancer, PSA testing, digital rectal examination, and transrectal ultrasound-guided biopsy have traditionally been used as standard methods [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, these methods have limitations, and the risk of complications due to excessive biopsies and the psychological burden on patients are issues, especially in the diagnosis of low-risk prostate cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, with the advancement of imaging diagnostic technology, more accurate non-invasive diagnostic methods have attracted attention in recent years [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Multiparametric magnetic resonance imaging (mpMRI) is becoming widely adopted as a promising diagnostic method because it can comprehensively evaluate prostate cancer's structural and functional information [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In particular, it has been reported that risk assessment using the Prostate Imaging-Reporting and Data System score is possible and is helpful as an indicator for appropriately determining the suitability of biopsy in low-risk patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Ultrasound imaging also plays an important role in the diagnosis of prostate cancer. Conventional transrectal ultrasound is widely used to evaluate the morphology of the prostate but has limited ability to identify cancer [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In addition, bone scintigraphy and computed tomography (CT) scans may be performed to confirm the presence or absence of metastasis when diagnosing prostate cancer. However, the introduction of these diagnostic technologies may vary depending on the medical institution's size, facilities, and personnel structure [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUniversity hospitals are well equipped with advanced imaging diagnostic equipment and specialists; in many cases, mpMRI diagnoses are performed as standard [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. On the other hand, while CT and mpMRI can be performed at community hospitals, post-diagnosis treatment options are limited due to the facility environment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, in clinics, it is common to focus on PSA and ultrasound tests at the early stage of diagnosis and refer patients to higher-level medical institutions as necessary. As such, there is an urgent need for more systematic investigations of the actual situation, especially regarding the differences in the testing methods and diagnostic strategies at the first consultation depending on the type of medical institution.\u003c/p\u003e\u003cp\u003eThis study aims to investigate the differences in image inspection and strategy of first-line treatment at the first consultation for low-risk prostate cancer patients between clinics, community hospitals, and university hospitals.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatement of ethics\u003c/h2\u003e\u003cp\u003eAll procedures in this study followed the 1964 Declaration of Helsinki according to the Strengthening the Reporting of Observational Studies in Epidemiology statement [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The study protocol was reviewed and approved by each Institutional Review Board. Moreover, informed consent was obtained from all of the patients, and they were provided with clear opportunities to opt out, respecting their autonomy and right to choose.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePatient eligibility\u003c/h3\u003e\n\u003cp\u003e Anonymized data of patients (almost all patients were Japanese) who were diagnosed low-risk prostate cancer, defined as PSA\u0026thinsp;\u0026le;\u0026thinsp;10, Gleason score\u0026thinsp;\u0026le;\u0026thinsp;6, and stage T1a-c/T2a, between 2016 and 2018 were obtained from a Japanese multicenter registry established by J-CaP. The cases (n\u0026thinsp;=\u0026thinsp;4) diagnosed with non-adenocarcinoma were excluded. Of the 16,623 patients, a total of 2,019 patients with low-risk prostate cancer were enrolled in this cohort study. A clinic was defined as a medical institution with 19 or fewer inpatient beds or no inpatient facilities, a community hospital was defined as a medical institution with 20 or more inpatient beds, and a university hospital was defined as a hospital established as a facility necessary for education and research for university medical and dental schools that train doctors and dentists. Patients\u0026rsquo; age, body mass index (BMI), PSA values, medical history, Gleason score, T stage, image inspection (CT scan, mpMRI scan, bone scintigraphy, Positron Emission Tomography (PET)-CT) and first-line treatment were all reviewed. The method of androgen deprivation therapy (ADT) was categorized as combined androgen blockade, castration monotherapy (surgical or medical castration) and others, including anti-androgen monotherapy, as described previously. This study retrospectively investigated the frequency of selection of active surveillance (AS)/watchful waiting (WW), ADT, curative radiotherapy, prostatectomy, and others (including docetaxel) as first-line treatments at each facility.\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eContinuous data, such as patient and tumor characteristics, are presented as median values with interquartile ranges (IQR). Categorical data are presented as counts and analyzed using Fisher\u0026rsquo;s exact test. Data with a normal distribution and a P-value of \u0026ge;\u0026thinsp;0.05 in the Shapiro\u0026ndash;Wilk test were analyzed using a t-test. In contrast, non-normally distributed data with a P-value of \u0026lt;\u0026thinsp;0.05 were analyzed using the Wilcoxon test. Tukey\u0026rsquo;s test was performed to compare the three group. All analyses used the JMP Pro version 18.0.0 for Mac (SAS. Institute Inc., Cary, NC, U.S.A.). The threshold for statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and all P-values were two-tailed. To provide a comprehensive understanding of the factors influencing the decision-making for image inspections and first-line treatment for low-risk prostate cancer, a multivariable analysis was performed. This analysis set up with the community hospital as the control group and included factors as below: age, PSA value, T stage, and facility.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003ePatients’ characteristics\u003c/h2\u003e\n \u003cp\u003eTable 1 showed a summary of the patient’s background characteristics. Patients’ age was different among clinic, community hospital and university hospital; elder in clinic and younger in university hospital. (clinic vs. community hospital, community hospital vs. university hospital, clinic vs. university hospital: p = 0.002, p = 0.002, P \u0026lt; 0.001 for each). No significant differences were observed between facilities regarding BMI, or medical history (hypertension, heart disease, hyperlipidemia, diabetes mellitus, pulmonary disease, gastric ulcer, and renal disease).\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBaseline Patient Demographics in three clinical locations\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCommunity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 1259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 (68–76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70 (65–75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (64–73)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e578 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e367 (54.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70–74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e360 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e190 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75–79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e242 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≦ 80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 (6.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.3 (21.9–25.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.7 (21.8–25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.7 (22.0–25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e581 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e282 (42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeart disease, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (2.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (4.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyper lipidemia, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e214 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131 (19.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (19.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e173 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePulmonary disease, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (2.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (1.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGastric ulcer, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (4.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRenal disease, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (2.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (2.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e; body mass index, IQR; interquartile range, \u003cem\u003ePSA\u003c/em\u003e; prostate specific antigen\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eProstate cancer’s characteristics\u003c/h2\u003e\n \u003cp\u003eTable 2 showed the result of cancer characteristics in this study. There were no significant differences in the Gleason score, total number of biopsy cores, or positive cores among the facilities. In terms of the TNM classification, the T stage was mostly T1c (74.1%) in clinics, while T2a was more frequently diagnosed in community hospital (34.9%), and furthermore in university hospital (41.9%).\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBaseline prostate cancer characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCommunity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 1259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSA, ng/mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.58 (4.46–7.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.68 (4.68–7.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.93 (4.79–7.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal Gleason score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 6, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1247 (99.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e664 (99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal cores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (12–14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (11–12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (10–14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of positive cores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1–2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1–3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2–3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT stage, (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (74.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e772 (61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e386 (57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e439 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e281 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eIQR; interquartile range\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eImage inspection for low-risk prostate cancer\u003c/h3\u003e\n\u003cp\u003eThe results of image examinations for staging performed on patients diagnosed with prostate cancer by prostate biopsy were shown in Table 3. The frequencies of CT scan were 46.1%, 89.8% and 87.2% in clinic, community hospital and university hospital, respectively (Table 3). MRI were performed in 59.6%, 64.5% and 85.0% of patients in clinic, community hospital and university hospital, respectively (Table 3). Bone scintigraphy were performed in 41.6%, 77.7% and 82.7% of patients in clinic, community hospital and university hospital, respectively (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eDetection and staging for prostate cancer\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCommunity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 1259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCT scan, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (46.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1131 (89.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e585 (87.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiparametric MRI scan, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (59.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e812 (64. 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e570 (85.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBone scintigraphy, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e978 (77.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e555 (82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePET CT scan, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cem\u003eCT\u003c/em\u003e; computed tomography, \u003cem\u003eMRI\u003c/em\u003e; Magnetic Resonance Imaging, \u003cem\u003ePET\u003c/em\u003e; Positron Emission Tomography.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe results of the multivariate analysis were shown in Table 4 about image inspections. Performing CT and MRI scans was negatively associated with the T2 stage (p \u0026lt; 0.001 for each). On the other hand, age, PSA values, pathological outcomes, and institution did not show a relationship with the decision to undergo image inspections.\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eMultivariable analysis on association between image inspections.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eCT scan\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMRI scan\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eBone scintigraphy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003ePET CT scan\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.285–5.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00–0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00–0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00–0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.989\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSA values, ng/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.620–5.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00–0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00–0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.146–3.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.653\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006–0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.187–0.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00–0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00–0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.989\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInstitution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.407–1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.737\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.547–2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.532–3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.608–5.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.747\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.553–1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.885–1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.838\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.632–3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.381–5.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"13\"\u003e\n \u003cp\u003e\u003cem\u003eCI;\u003c/em\u003e confidence interval, \u003cem\u003eCT\u003c/em\u003e; computed tomography, \u003cem\u003eOR\u003c/em\u003e; odds rate, \u003cem\u003eMRI\u003c/em\u003e; magnetic resonance imaging, \u003cem\u003ePET\u003c/em\u003e; positron emission tomography, \u003cem\u003ePSA\u003c/em\u003e; prostate–specific antigen, \u003csup\u003e*\u003c/sup\u003eStatistically significant (P \u0026lt; 0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFirst-line treatment for low-risk prostate cancer\u003c/p\u003e\n\u003cp\u003eTable 5 showed a result of the treatment strategy for low-risk prostate cancer in each institution. AS was chosen for 34.8%, 46.2% and 33.5% of patients with low-risk prostate cancer in clinic, community hospital and university hospital, respectively (Table 5). ADT was performed in 42.7%, 8.66% and 3.28% of patients with low-risk prostate cancer in clinic, community hospital and university hospital, respectively (Table 5). The frequencies of curative radiation were 2.25%, 13.6% and 28.0% in clinic, community hospital and university hospital, respectively (Table 5). The frequencies of prostatectomy were 12.4%, 29.4% and 34.9% in clinic, community hospital and university hospital, respectively (Table 5).The results of the multivariate analysis about first-line treatment for low-risk prostate cancer were shown in Table 6. High PSA value was significantly associated less likely with AS (odds ratio [OR], 0.650; p = 0.014) and androgen deprivation therapy (OR, 0.443; p = 0.001), but more likely with prostatectomy (OR, 3.79; p \u0026lt; 0.001). Also, T2 stage was significantly associated less likely with androgen deprivation therapy (OR, 0.302; p \u0026lt; 0.001). Regarding institutions, clinics (OR, 0.592; p = 0.023) and university hospitals (OR, 0.590; p \u0026lt; 0.001) were significantly associated with less choice of AS/WW. The use of ADT was more frequent in clinic (OR, 7.93; p \u0026lt; 0.001), but less frequent in university hospital (OR, 0.398; p \u0026lt; 0.001). Curative radiation was chosen less frequently in clinic (OR, 0.146; p = 0.008), but more frequently in university hospital (OR, 2.43; p \u0026lt; 0.001). Similarly, prostatectomy was chosen less frequently in clinic (OR, 0.356; p = 0.002).\u003c/p\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eFist-line treatment for prostate cancer\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCommunity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 1259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003en = 671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive surveillance/watchful waiting, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e587 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e225 (33.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAndrogen deprivation therapy, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109 (8.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (3.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurative radiation, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e171 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e188 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProstatectomy, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e370 (29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e234 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (7.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (1.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 6\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eMultivariable analysis on association between first line treatments for low–risk prostate cancer.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eActive surveillance/watchful waiting\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eAndrogen deprivation therapy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eCurative radiation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eProstatectomy\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.846\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.610–1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.687–1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.745–1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.787–1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSA values, ng/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.460–0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.014\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.277–0.710\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.611–1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.973\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.18–6.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.760–1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.169–0.565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.698–1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.757\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.805–1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.460\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInstitution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.592\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.376–0.930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.023\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.89–12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.036–0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.186–0.681\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e–\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.485–0.718\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.248–0.638\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.92–3.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.999–1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"13\"\u003e\n \u003cp\u003e\u003cem\u003eCI;\u003c/em\u003e confidence interval, \u003cem\u003eOR\u003c/em\u003e; odds rate, \u003cem\u003ePSA\u003c/em\u003e; prostate–specific antigen, \u003csup\u003e*\u003c/sup\u003eStatistically significant (P \u0026lt; 0.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"},{"header":"Discussions","content":"\u003cp\u003eIn this study, we used a multi-institutional Japan-wide database to investigate image inspection for staging after diagnosis and the subsequent treatment status of patients with low-risk prostate cancer. Although our analysis showed no difference in the type of image inspection selected by institution, there were differences in first-line treatment by institution. This analysis suggests that elucidating the actual treatment status of low-risk prostate cancer may contribute to correcting the treatment disparity by institution.\u003c/p\u003e\u003cp\u003eAS is considered an important option in the management of low-risk prostate cancer [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This AS has emerged as a management approach for prostate cancer with a good prognosis in response to the overtreatment of low-grade disease caused by the introduction of PSA screening. By monitoring with PSA values, regular prostate biopsies, and mpMRI, definitive treatment can be postponed until signs of cancer progression appear or avoided entirely if progression is not detected, and it is expected to reduce common side effects associated with treatment [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Newcomb et al. demonstrated that 10 years after diagnosis, approximately half of the men undergoing AS for favorable prostate cancer have progressed or are not treated, less than 2% have developed metastatic disease, and less than 1% have died of disease.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] This report implied that men who were treated immediately after the first biopsy after diagnosis had similar long-term clinical outcomes of adverse pathological outcomes, recurrence, or metastasis to those who were treated after several years of surveillance. In a cohort study of AS in the Japanese population, approximately 30% of patients had pathological reclassification during biopsy, but the acceptance rate of biopsy declined over time, and six patients had metastases and one patient died of prostate cancer [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As a result, AS is becoming established as an option for low-risk prostate cancer in Japan [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Radiation therapy is also an option, and Lee et al. reported that in men with low-risk prostate cancer, 70 Gy in 28 fractions over 5.6 weeks had equivalent outcomes to 73.8 Gy in 41 fractions over 8.2 weeks [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, the results of the PACE-B trial showed that five-fraction stereotactic body radiotherapy was a potent and feasible alternative to moderately fractionated radiotherapy for prostate cancer, providing similar efficacy and improved patient convenience [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A 15-year follow-up study of localized prostate cancer by Hamdy et al. showed that there was no significant difference in prostate cancer mortality among the three treatments of AS, surgery, and radiotherapy, suggesting that AS is an appropriate option, especially for low-risk patients with a life expectancy of more than 10 years [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. While, in low-risk patients with a life expectancy of below 10 years, observation is recommended [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In this study, AS/WW was chosen in less than 35% of patients, suggesting an insufficient implementation of AS/WW for low-risk prostate cancer. However, Similar data that AS was chosen in 37% of low-risk prostate cancer between 2016 and 2018 in the United States was reported [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These findings suggest that low implementation of AS is a global issue although AS implementation rate rapidly increased to 60% in 2021 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study revealed less choice of AS/WW and curative treatment, but overuse of ADT in clinic. Less use of curative treatment may be influenced by higher age of patients in clinics. However, less use of AS/WW and overuse of ADT is not justified by higher age because those options may be harmful due to its adverse effect with less clinical benefit for low-risk prostate cancer. While curative treatment instead of AS/WW was chose more frequently in university hospital, which may be due to younger age, higher PSA level and higher T-stage in university hospital.\u003c/p\u003e\u003cp\u003eOur study had several limitations. This study was conducted at multiple facilities in Japan, which may lead to heterogeneity in patient treatment and monitoring. Furthermore, this study did not include long-term treatment outcomes of therapeutic interventions. Therefore, further investigation of the effectiveness of each treatment option for low-risk prostate cancer was required. Finally, the patients who participated in this study were from Japan, and the application of these findings to other races, and regions, may be limited. Despite these limitations, this study analyzed the approach and treatment strategy for low-risk prostate cancer by type of medical institution in Japan, and the results showed that the difference in type significantly affects the treatment strategy for low-risk prostate cancer.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study analyzed data on low-risk prostate cancer obtained from a Japanese multi-institutional registry and found no differences in diagnostic image examinations by type of medical institution but did find differences in first-line treatment options by type of medical institution. The findings indicated a disparity of strategies for low-risk prostate cancer by facility type; less use of AS/WW and curative treatment, but an overuse of ADT in clinics while less use of AS/WW and ADT, but an overuse of curative treatment in university hospital for low-risk prostate cancer in Japan, suggesting an insufficient implementation of AS/WW in clinics and university hospital, and overuse of ADT in clinics.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADT; androgen deprivation therapy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAS; active surveillance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT; computed tomography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIQR; interquartile ranges\u0026nbsp;\u003c/p\u003e\n\u003cp\u003empMRI; multiparametric magnetic resonance imaging\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePET; positron emission tomography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePSA; prostate-specific antigen\u003c/p\u003e\n\u003cp\u003eWW; watchful waiting\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to resources, and writing\u0026ndash;review and editing. S.K. contributed to formal analysis, investigation, visualization, and writing\u0026ndash;original draft. M.S. contributed to conceptualization. M.O. contributed to administration. H.K. contributed to supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the patients whose data were analyzed in this study and all investigators involved. We appreciate the excellent support from Ms. Tae Nakano.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch involving human participants and / or animals:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support this study\u0026rsquo;s findings are available from the corresponding author [Satoshi Kobayashi], upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor disclosure statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no relevant financial interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray, F., Laversanne, M., Sung, H., Ferlay, J., Siegel, R. L., Soerjomataram, I., \u0026amp; Jemal, A. (2024). 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Long-term outcomes in patients using protocol-directed active surveillance for prostate cancer. \u003cem\u003eJAMA\u003c/em\u003e, \u003cem\u003e331\u003c/em\u003e(24), 2084-2093. doi: 10.1001/jama.2024.6695.\u003c/li\u003e\n\u003cli\u003eKato, T., Matsumoto, R., Yokomizo, A., Tohi, Y., Fukuhara, H., Fujii, Y., ... \u0026amp; Sugimoto, M. (2024). Outcomes of active surveillance for Japanese patients with prostate cancer (PRIAS‐JAPAN). \u003cem\u003eBJU international\u003c/em\u003e, \u003cem\u003e134\u003c/em\u003e(4), 652-658. doi: 10.1111/bju.16436.\u003c/li\u003e\n\u003cli\u003eKawai, T., Onozawa, M., Taguchi, S., Shiota, M., Sakamoto, S., Yamamoto, Y., ... \u0026amp; Japan Study Group of Prostate Cancer (J-CaP). (2024). Changes in the trends of initial treatment for newly diagnosed prostate cancer in Japan: a nationwide multi-institutional study. \u003cem\u003eJapanese Journal of Clinical Oncology\u003c/em\u003e, \u003cem\u003e54\u003c/em\u003e(9), 1045-1051. doi: 10.1093/jjco/hyae079.\u003c/li\u003e\n\u003cli\u003eLee, W. R., Dignam, J. J., Amin, M., Bruner, D., Low, D., Swanson, G. P., ... \u0026amp; Sandler, H. M. (2016). NRG Oncology RTOG 0415: A randomized phase III non-inferiority study comparing two fractionation schedules in patients with low-risk prostate cancer. doi: 10.1200/JCO.23.02445.\u003c/li\u003e\n\u003cli\u003evan As, N., Griffin, C., Tree, A., Patel, J., Ostler, P., van der Voet, H., ... \u0026amp; Hall, E. (2024). Phase 3 trial of stereotactic body radiotherapy in localized prostate cancer. \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e, \u003cem\u003e391\u003c/em\u003e(15), 1413-1425. doi: 10.1056/NEJMoa2403365.\u003c/li\u003e\n\u003cli\u003eHamdy, F. C., Donovan, J. L., Lane, J. A., Metcalfe, C., Davis, M., Turner, E. L., ... \u0026amp; Neal, D. E. (2023). Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e, \u003cem\u003e388\u003c/em\u003e(17), 1547-1558. doi: 10.1056/NEJMoa2214122.\u003c/li\u003e\n\u003cli\u003eGallagher, K. M., Christopher, E., Cameron, A. J., Little, S., Innes, A., Davis, G., ... \u0026amp; McNeill, A. (2019). Four‐year outcomes from a multiparametric magnetic resonance imaging (MRI)‐based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies. \u003cem\u003eBju International\u003c/em\u003e, \u003cem\u003e123\u003c/em\u003e(3), 429-438. doi: 10.1111/bju.14513.\u003c/li\u003e\n\u003cli\u003eCooperberg, M. R., Meeks, W., Fang, R., Gaylis, F. D., Catalona, W. J., \u0026amp; Makarov, D. V. (2023). Time trends and variation in the use of active surveillance for management of low-risk prostate cancer in the US. \u003cem\u003eJAMA network open\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(3), e231439-e231439. doi: 10.1001/jamanetworkopen.2023.1439. doi: 10.1001/jamanetworkopen.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"prostate cancer, low risk, active surveillance, prostatectomy","lastPublishedDoi":"10.21203/rs.3.rs-6641831/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6641831/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e\u003cp\u003eThere is an urgent need for more systematic investigations into how imaging inspection and primary treatment for low-risk prostate cancer vary by type of medical institution. To investigate disparities in imaging inspections and first-line treatment depending on the type of medical institution for low-risk prostate cancer using the Japan Study Group of Prostate Cancer database.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eData on patients with low-risk prostate cancer diagnosed between 2016 and 2018 from a nationwide database of the Japan Study Group of Prostate Cancer were used. Among these databases, patient and tumor characteristics, image inspections for diagnosis, and first-line treatment at clinics, community hospitals, and university hospitals were compared statistically.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThis analysis included patients with low-risk prostate cancer at clinics (n\u0026thinsp;=\u0026thinsp;89), community hospitals (n\u0026thinsp;=\u0026thinsp;1259), and university hospitals (n\u0026thinsp;=\u0026thinsp;671). The three facilities had no significant differences in the performance of computed tomography scans, bone scintigraphy, and magnetic resonance imaging scans. Active surveillance was less performed in clinics and university hospitals, compared with community hospitals. Androgen deprivation therapy was significantly more common, but curative treatments, including radiation and prostatectomy, were less performed in clinics. Curative radiation was significantly more common, but androgen deprivation therapy was less performed in university hospitals.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eOur study analyzed data on low-risk prostate cancer obtained from a Japanese multi-institutional registry and showed differences in first-line treatment options by type of medical institution.\u003c/p\u003e","manuscriptTitle":"The disparity of strategies for low-risk prostate cancer by facility type using a multi-institutional Japan-wide database","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 11:14:30","doi":"10.21203/rs.3.rs-6641831/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b338ed74-2ba1-4be9-9592-610666e8d2c4","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-30T06:23:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-18 11:14:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6641831","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6641831","identity":"rs-6641831","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}