This retrospective study used the National Cancer Database (NCDB) to identify patients 50 years or older with nonmetastatic prostate cancer diagnosed between 2010 and 2023 and seen at US centers with Commission on Cancer accreditation.9 Treatment categories were derived from NCDB first-course treatment variables. The study was approved by the University of Pittsburgh institutional review board (STUDY26020146) and followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.10
Inappropriate focal therapy use was defined as focal therapy in low-, high-, or very–high-risk disease.2 Intermediate-risk focal therapy was reported separately because the NCDB does not capture trial enrollment, registry participation, or lesion characteristics needed to classify appropriateness.
Temporal trends were assessed using Cochran-Armitage tests. Multivariable logistic regression evaluated patient-and facility-level characteristics associated with focal therapy vs radical prostatectomy. Adjusted predicted probabilities and average marginal effects were estimated using facility-clustered robust standard errors. The eMethods in Supplement 1 provide additional methodologic detail.