Active Surveillance versus Definitive Treatment for Pituitary Adenomas: A Population-Based and Propensity Score Analysis

Introduction: There are currently no large-sample studies assessing the clinical outcomes of pituitary adenomas (PA) patients undergoing active surveillance (AS) versus definitive treatment (DT). This population-based analysis aims to identify clinical and sociodemographic predictors of undergoing AS and compare clinical outcomes of PA patients undergoing AS versus DT.

Design: The National Cancer Database (NCDB) was utilized to query PA patients diagnosed from 2010 to 2015 undergoing AS or DT. Propensity score-matching was performed to simulate randomization and control for baseline differences in age, comorbidities, and tumor size.

Results: The cohort consisted of 30,233 PA patients, with 5,147 (17.0%) patients undergoing AS. PA patients undergoing AS presented with significantly smaller tumors (12.7 ± 10.5 vs. 22.7 ± 12.7; p < 0.001) and lived significantly closer to their provider (28.5 ± 100.3 vs. 48.8 ± 135.4; p < 0.001) compared with PA patients undergoing DT. Rates of AS and DT remained stable from 2010 to 2015 (R ² = 0.32; p = 0.24; [Fig. 1]). On multivariate binary logistic regression, patients aged ≥65 years (OR = 1.65; p < 0.001), African American race (OR = 1.12; p = 0.035), having government insurance (OR = 1.45; p < 0.001), or those uninsured (OR = 1.58; p < 0.001) were significantly more likely to undergo AS compared with DT, while patients with larger tumors (OR = 0.90; p < 0.001), receiving treatment at academic facilities (OR = 0.75; p < 0.001), and living in West regions of the United States (OR = 0.59; p < 0.001) were significantly less likely to undergo AS compared with DT. The propensity score-matched cohort consisted of 6,770 PA patients with equal proportion of patients undergoing AS and DT. The 1, 2, and 5-year OS rates for patients undergoing DT were 96.5% (95% CI: 95.9–97.2%), 94.9% (95% CI: 94.1–95.6%), and 89.1% (95% CI: 87.8–90.5%), respectively, while the 1, 2, and 5-year OS rates for patients undergoing AS were 96.4% (95% CI: 95.8–97.1%), 93.1% (95% CI: 92.2–94.0%), and 92.8% (95% CI: 81.1–84.6%), respectively. On multivariate Cox proportional-hazards analysis, undergoing AS (HR = 1.46; p < 0.001) was significantly associated with increased mortality. Patients with microadenomas (≤1 cm) had no significant differences (p = 0.27) in OS when undergoing AS or DT ([Fig. 2]).

Conclusion: Significant sociodemographic disparities exist in patient selection for undergoing AS, such as patient race and insurance status. These results may help guide physicians toward counseling patients that more aggressive upfront treatment for macroadenomas may provide better long-term clinical outcomes.

Fig. 1 Trends of treatment over time between 2010 and 2015. The graph represents stable rates of active surveillance (AS) and definitive treatment (TX) over time (R ² = 0.32; p = 0.24).

Fig. 2 (A) Kaplan–Meier curve of overall survival for pituitary adenoma patients with microadenomas (≤1 cm) matched on age, C/D, and tumor size comparing active surveillance versus definitive treatment. (B) Kaplan–Meier curve of overall survival for pituitary adenoma patients with macroadenomas (>1 cm) matched on age, C/D, and tumor size comparing active surveillance versus definitive treatment.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021