Clinicians say active surveillance is effective but rarely recommend it

The majority of urologists and radiation oncologists feel active surveillance is an effective and underused modality for managing low-risk prostate cancer; however, few of these specialists would recommend this strategy to patients, according to recent survey results.

The study authors suggest that wider use of decision aids in clinical practice would allow active surveillance to become a more acceptable strategy among both low-risk prostate cancer patients and specialists. That recommendation was echoed by a leading prostate cancer expert with experience with a shared decision-making program.

For the study, which was published in Medical Care (2014; 52:579-85), the authors analyzed survey responses from 717 U.S. urologists and radiation oncologists. They found that 72% of the specialists agreed that active surveillance is an effective alternative for men with low-risk prostate cancer. In addition, 80% said they agreed that active surveillance was underused in the United States.

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However, the majority of respondents (60% of urologists and more than 80% of radiation oncologists) said that their patients were not interested in active surveillance. In addition, when asked what course of treatment they would recommend for a hypothetical 60-year-old man with low-risk prostate cancer, only 22% of the specialists chose active surveillance

Instead, the specialists were more likely to recommend either surgery or radiation, depending on their specialty; urologists were more likely to recommend surgery, whereas radiation oncologists were more likely to recommend radiation therapy. In addition, urologists were more than twice as likely to recommend active surveillance than radiation oncologists were, the authors reported.

"Our study suggests that there remain some key attitudinal barriers to active surveillance among prostate cancer specialists, especially considering radiation oncologists and urologists may view their treatment as superior,” wrote the authors, led by first author Simon P. Kim, MD, of Yale School of Medicine, New Haven, CT.

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Dr. Kim and his co-authors discussed some options to better incorporate patient preferences into treatment decisions, such as decision aids to provide men with evidence-based data on the advantages and disadvantages of treatment options.

The recommendation of additional data to help patients was lauded by Urology Times Editorial Council member Leonard G. Gomella, MD, of Thomas Jefferson University and the Kimmel Cancer Center, Philadelphia.

“The concept that a cancer may not need to be treated is certainly foreign to most patients. Dr. Kim and colleagues appropriately note that increased education at the time of diagnosis about active surveillance may help in the decision process. At the Jefferson Kimmel Cancer Center GU multidisciplinary clinic, we have developed a ‘Decision counseling and shared decision making’ program that has helped men become better informed about treatment choices and reduced uncertainty in treatment decision making.

The combined intervention resulted in more men choosing active surveillance,” said Dr. Gomella, who was not involved with the study.

In addition to boosting patient awareness, Dr. Gomella predicted that emerging clinical advances will increase clinicians’ confidence in recommending active surveillance.

“As more robust tools, such as genomic predictors, evolve as discriminators of favorable outcome, individual physicians’ confidence in the recommendation for active surveillance will inspire more confidence in men to make that choice,” Dr. Gomella told Urology Times.

Dr. Gomella noted that, while the current paper suggests most specialists don’t recommend active surveillance often, it is clearly an appropriate option for many low-risk prostate cancer patients, and intermediate-term actuarial survival data support its utility.

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