How Active is Active Surveillance in Prostate Cancer?

Active Surveillance in Prostate Cancer

Karim Chamie, MD

A new study¹from the University of California, Los Angeles (UCLA) shows that less than 5% of men who opt for active surveillance of their low-risk prostate cancer receive the proper amount of monitoring. Improper monitoring of prostate cancer could result in progression or metastases.

The objective of the study published inCancer, was to find the population-based intensity of active surveillance strategies among men diagnosed with low-risk prostate cancer against those who opt for active, aggressive treatment. According to a press release from UCLA,²an increasing number of men diagnosed with low-risk prostate cancer forgo treatment in favor of surveillance due to treatment toxicities. These toxicities may include urinary dysfunction, bowel dysfunction, erectile dysfunction, and loss of fertility.³

“This is really an important finding, because before patients and their doctors decide to pursue active surveillance as a management option for prostate cancer, both the physician and patient should agree on a follow-up schedule to closely monitor the cancer,” said lead author Karim Chamie, MD, surgical director of the Bladder Cancer Program, UCLA, in a news release.

“What was most surprising was that patients who underwent aggressive treatment for their prostate cancer were more likely to receive routine lab testing and visits with their doctor than those not receiving aggressive treatment. In other words, those likely cured through aggressive treatment were followed more closely than patients whose cancers were left untreated.”

The study examined data from 37,687 men diagnosed with prostate cancer between 2004 and 2007, and data were examined until December 31, 2009. Due to complete data on clinical staging and biopsy grade not being available through Surveillance, Epidemiology, and End Results (SEER), as summarized in Patient Entitlement and Diagnosis Summary File (PEDSF), patients diagnosed before then were excluded in order to standardize the cohort.

Of the patients involved, 3656 opted for active surveillance. One-hundred and sixty six of those men, roughly 4.5%, received the proper amount of surveillance needed, while the rest did not. The study states that number did increase over the final 2 years of the study.

According to the study, patients who underwent active surveillance were less likely to undergo PSA testing or to attend office visits within the 2 years after diagnosis. This is in comparison with those who received other types of treatments (P< .01). The mean number of patients in the active surveillance cohort who underwent PSA tests and attended office visits within the 2 years of their diagnosis were 2.6 tests and 4.6 visits, respectively.

Additionally, 13% of men in the same group received a second biopsy within 2 years of diagnosis, while 66% to 71% of patients with a Gleason score of 6 through 10 did not receive at least 4 PSA tests within those same 2 years.

The conclusion of the study stated that active surveillance is underused and the quality of surveillance given to patients is still unclear. The authors stated that further research should be conducted to properly describe the contributing factors that drive men's decision-making. Research should also be conducted for improving methods for properly monitoring men with low-risk prostate cancer.

&ldquo;Many researchers have been advocating for active surveillance for men with low-risk disease,&rdquo; said Chamie. &ldquo;However, this study suggests that before we advise our patients to pursue active surveillance for their prostate cancers, we should be certain that we are committed to closely monitoring the cancers with a repeat biopsy, PSA testing, and physical exams.&rdquo;

The study conducted by UCLA researchers was the first population-based study to compare the results of follow-up intensity in American men with low-risk prostate cancer who refused treatment, such as surgery or radiation. According to the news release, a proper regimen for active surveillance includes testing for prostate-specific antigen (PSA), office or facility visits for physical examinations, and at least one additional prostate biopsy within a 2-year period of diagnosis.

Researchers found a small, statistically-significant increase in follow-up intensity with time throughout the study, meaning men were more likely to receive the recommended tests over a longer period of time. Chamie stated in the news release that he and his team would like to determine if the increase will plateau and eventually shrink, or continue in its growth.

The study originally identified 45,408 men in SEER-Medicare linked data for the study. Men were then excluded due to a diagnosis being obtained from death certificate or autopsy, low-risk prostate cancer not being their first and only malignancy, prostate cancer not being pathologically confirmed, being enrolled in Medicare for end-stage renal disease or disability, date of diagnosis in SEER and Medicare data conflicted by over a 3-month period, younger than 65 years of age at diagnosis, not being enrolled in Medicare parts A or B, lacking information 1 year before and 2 years after diagnosis, lacking diagnostic biopsy, unknown Gleason grade and clinical stage, or unknown socioeconomic status.

In 2012, according to the most recent data from the Centers for Disease Control and Prevention,⁴177,484 men in the United States were diagnosed with prostate cancer and 27,244 died from the disease.

References

1. Chamie K, Williams S, Hershman D, Wright J, Nguyen P, Hu J. Population-based assessment of determining predictors for quality of prostate cancer surveillance.Cancer. 2015;121(23):4150-4157. doi:10.1002/cncr.29574.
2. Irwin K. Men who forgo aggressive treatment for prostate cancer don&rsquo;t receive appropriate monitoring.UCLA Newsroom. 2015. Available at: http://newsroom.ucla.edu/releases/men-who-forgo-aggressive-treatment-for-prostate-cancer-dont-receive-appropriate-monitoring. Accessed December 3, 2015.
3. Pcf.org. Side Effects - Prostate Cancer Foundation (PCF). www.pcf.org/site/c.leJRIROrEpH/b.5822789/k.9652/Side_Effects.htm. Accessed December 3, 2015.
4. Cdc.gov. CDC - Prostate Cancer Statistics. 2015. http://www.cdc.gov/cancer/prostate/statistics/. Accessed December 3, 2015.