Introduction: Prostate biopsy interpretation is inherently operator-dependent, and some treating physicians may rely on a second opinion evaluation of slides procured elsewhere. Using population-level billing claims, we assessed utilization of second opinion prostate biopsy evaluations and their association with treatment patterns, geographic location, and other patient-related factors. Methods: Using the IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases, we identified men newly diagnosed with prostate cancer from 2017 through 2020. The analytic cohort was limited to those with at least 6 months of available claims following their diagnostic biopsy. Factors of interest included patient factors (e.g., age, health plan) and geographic location based on metropolitan statistical area. We also assessed variation in subsequent management (prostatectomy, radiation/brachytherapy, surveillance/no treatment) based on receipt of second opinion biopsy evaluation. Multivariable regression analysis was performed to evaluate the association between second opinion biopsy and treatment received. Results: Of 1,081,999 eligible patients in our dataset, 27,627 patients met inclusion criteria for our analytic cohort. Of these, 4,241 (15.4%) underwent second opinion prostate biopsy. The median time to a second opinion was 43 days (IQR 24 – 77). Its use has become less common over time (16.7% 2017 vs 11.5% 2020, p<0.001). This was more common among younger patients ( <55 years vs 75+ years, 19.7% vs 9.1%, p<0.001) and those in the Northeast (24.8% vs 11.4% North Central, p>0.001). Regarding treatment, prostatectomy patients were most likely to have had a second opinion biopsy evaluation (18.6%) followed by radiation/brachytherapy (14.0%) and then surveillance/no treatment (12.5%). After adjustment for other factors, patients receiving a second opinion prostate biopsy evaluation had 28% lower odds of undergoing surveillance/no treatment (vs prostatectomy/radiation/brachytherapy, adjusted OR 0.72 (95% CI 0.67 – 0.77). Conclusions: Second opinion prostate biopsy interpretation is common, and its use varies significantly based on patient related factors. The association between second opinion biopsies and treatment patterns, where surveillance was less common, merits exploration to assess how it may be related to grade reclassification versus previously established provider-level practice patterns. SOURCE OF Funding: Winship Cancer Institute Pilot Grant, Emory University, Atlanta, GA
