Why is AS for prostate Ca not used more?

A new study by Aragon-Ching et al reported that from 1998 to 2012, only 7.5% and 2.2% of men with TNM stage I and II prostate cancer in the National Cancer Database were managed with active surveillance (AS). These results are surprising in light of several other recent studies reporting higher uptake of AS (40%-50%) among low-risk patients in the CaPSURE, MUSIC, and New Hampshire registries by 2013 (JAMA 2015; 314:80-2; Eur Urol 2015; 67:44-50; Cancer Causes Control 2015; 26:923-9). Of note, none of these registries provides coverage across the entire U.S., and AS itself may be difficult to define using administrative data.

In Sweden, 91% of very low-risk and 74% of low-risk patients were managed with AS in 2014, as were 19% of intermediate-risk patients (JAMA Oncol Oct 20, 2016 [Epub ahead of print]). There is now general consensus on the use of AS for low-risk prostate cancer, and the debate has shifted to defining a group with intermediate-risk disease who might defer upfront treatment.

Why is AS so much lower in the U.S. than in Sweden? Our group recently performed a qualitative study of prostate cancer providers to explore the practice patterns and potential barriers to AS in this country (BJU Int Sept. 9, 2016 [Epub ahead of print]). Some emerging themes were concerns about missing the window for cure, insufficient education on AS during training, lack of a single international standard protocol, financial and medicolegal considerations, and patient preferences.

Numerous initiatives are ongoing to increase AS uptake. One such effort is new nomenclature to report prostate cancer grade, in which Gleason 6 (out of 10) is now referred to as Grade Group 1 (out of 5). Patients report feeling more comfortable with AS for a “Grade Group 1” versus a “Gleason 6” (Eur Urol 2016; 70:1083-5). Other interventions target physicians, such as specialized training on how to counsel patients about AS and dashboards for comparative feedback (Eur Urol Jan. 24, 2017 [Epub ahead of print]; Urology 2016; 93:60-7).

A recent mathematical model showed that screening is cost-effective if low-risk cases are managed with AS (JAMA Oncol 2016; 2:890-8). Indeed, increased use of AS was among the reasons why the U.S. Preventive Services Task Force recently updated from a D recommendation (against screening) to a C recommendation (shared decision-making).

As a urologic community, we should promote the use of AS for favorable-risk disease to reduce the downstream harms of screening while preserving the benefits of early detection for life-threatening cases.

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