Active surveillance on the rise but still underused

Active surveillance and watchful waiting for men diagnosed with low-risk, localized prostate cancer grew rapidly from 2010 through 2013, a new study of community-based management trends reports. Nevertheless, most low-risk patients still undergo surgical or radiation treatment, according to a review of expectant management in such men.

Matthew R. Cooperberg, MD, MPH, and Peter R. Carroll, MD, MPH, of the University of California, San Francisco, analyzed data from the Cancer of the Prostate Strategic Urologic Research Endeavor, a national registry of men diagnosed with prostate cancer at 45 urology practices since 1995. The analysis included 10,472 men, average age 66 years, with stage cT3aNoMo (localized) or lower prostate cancer (low, medium, and high risk) who were managed between 1990 and 2013 with prostatectomy, radiation, androgen deprivation monotherapy, or active surveillance/watchful waiting. 

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Surveillance for low-risk cancer, which had varied from 6.7% to 14% from 1990 through 2009, jumped to 40.4% from 2010 through 2013. Surveillance rates for men 75 years of age or older, which were 54% from 1990 through 1994 but decreased to 22% from 2000 through 2004, rose to 76.2% from 2010 through 2013.

“The magnitude and speed of the changes suggest a genuine change in the management of patients with prostate cancer in the United States, which could accelerate as more clinicians begin to participate in registry efforts,” wrote the authors in a research letter published in JAMA (2015; 314:80-2).

NEXT: Expectant management remains underused

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Despite increasing use of active surveillance and watchful waiting in men with low-risk, localized prostate cancer, expectant management remains underused, the authors of a review published in CA: A Cancer Journal for Clinicians (2015; 65:264-82) maintain.

Most low-risk patients still undergo surgery or radiation with attendant risks of long-term side effects such as erectile dysfunction and impaired urinary function, they note, even though expectant management has been shown to result in excellent long-term cancer-specific survival with minimal morbidity.

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As many as 40% of patients may currently be overtreated, said senior author Mark Litwin, MD, MPH, of UCLA.

“This study is the most up-to-date and comprehensive review of expectant management of prostate cancer patients worldwide. This represents an important resource for patients and providers considering surveillance for prostate cancer. Active surveillance and other observational strategies have produced excellent, long-term disease-specific survival and minimal morbidity for men with prostate cancer. Despite this, expectant management remains underused for men with localized prostate cancer,” Dr. Litwin said in a UCLA press release.

NEXT: Review discusses types of surveillances, describes current protocols

In the review, Dr. Litwin and colleagues clarify the definitions of types of surveillance, making it easier for physicians and their patients to decide which is best for them. They also describe current surveillance protocols, and review the outcomes for each of these strategies in terms of cancer survival and quality of life. Additionally, the review addresses novel technologies such as prostate magnetic resonance imaging and fusion biopsies that may prove beneficial for surveillance patients.

“Active surveillance is a viable approach for most men with low-risk prostate cancer, and its broader adoption has the potential to stop the overtreatment of men with indolent lesions and redirect resources to men with more serious cancers,” the authors concluded.

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