Active surveillance has been designed to address the “overtreatment” side of the justifiable double criticism of “overdiagnosis and overtreatment” of low-risk prostate cancer. Considering its real potential, AS is currently underutilized as a management option in men with favorable risk prostate cancer.
Acceptance of AS is increasing, but participation begins at a low level. Practice patterns for choice of initial therapy for men with localized prostate cancer was addressed by Drs. Cooperberg et al. (J Clin Onco. 2010 Mar).
Their survey covered 11,892 men in 36 clinical sites followed in the CaPSURE registry.
Results: 6.8% elected surveillance, 49.9% prostatectomy, 11.6% external-beam radiation, 13.3% brachytherapy, and 4.0% cryotherapy.
“Treatment patterns vary markedly across clinical sites, and this variation is not explained by case-mix variability or known patient factors.”
In the 2012 National Institutes of Health conference on Active Surveillance it was estimated that, of the 100,000 men yearly diagnosed with low-risk prostate cancer who were eligible for AS only, 10% would choose this option. (Ganz, Ann Int Med. 2012 April)
A current report, “Contemporary Use of Initial Active Surveillance Among Men in Michigan with Low-risk Prostate Cancer” (Womble, Eur Oncol. Jan 2015) noted that the historical rate of acceptance of AS was between 4 and 20%.
In their study of 682 men from 17 community practices 49% underwent initial AS, but, echoing Cooperberg, the authors found, “Use of initial surveillance varied widely across practices (27% – 80%; p = 0.005), even after accounting for difference in patient characteristics.”
Dr. Dall’Era (Curr Opin Urol. 2015 May) in discussing “Patient and disease factors affecting choice and adherence to active surveillance” spoke to the essence of this issue: “Treatment decisions for prostate cancer are strongly associated with physician recommendations, and a high quality relationship between the patient and his health care system is critical to successful active surveillance.”
Dr. Ballentine Carter, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine is a dedicated proponent, writer, and researcher regarding AS. He has thoughtfully addressed “The disconnect between evidence and practice with respect to management of favorable risk prostate cancer [that] has resulted in overtreatment.”
In his article, “Aligning evidence and practice: future research needs to increase utilization of active surveillance for favorable risk prostate cancer”, he cites three areas where improvement may support increased enrollment and provide greater confidence of long-term success to men considering AS.
- “Risk Classification”: Even the most strict classification schemes for enrollment undergrade cancers in 20% – 30% of cases leading to early intervention in 2 – 3 years. More accurate classification can result from the use of multiparametric MRI/TRUS targeted biopsies and “genetic profiling of prostate cancer using prostate biopsy tissue.”
Of interest is his preference for assessing risk by testing for the tumor suppressor, PTEN, as opposed to a currently available genetic profiler (Prolaris), which “did not significantly add to the prediction of prostate cancer death among men with low-grade disease who would be considered for surveillance” (citing Cuzick, British Journal of Cancer. 2012 Feb).
- “Protocol Standardization”: The NIH conference on AS noted the variability of AS schemas as an impediment to future research. Carter cites two ongoing programs which harness ‘big’ data to address some of the unanswered questions with regard to active surveillance: “Global Action Plan 3 (GAP3)” and “Prostate Modeling to Identify Surveillance Strategies (PROMISS).”
- “Patient Decision Support”: For making an appropriate decision for his care a patient needs a “clear understanding of risk and benefits of both surveillance and curative intervention.” Bias toward his own treatment modality has been show to enter into a specialist’s recommendation. “Multidisciplinary care may reduce some of this bias,” as can consultations with different specialists in the several treatment modalities. In addition, decision support tools can provide patients with information about “treatment options and improve patient satisfaction with decision making and decrease a patient’s decisional conflict.”
BOTTOM LINE: Active surveillance is currently underused as a management strategy but its acceptance is increasing. Improvements in risk stratification, protocol standardization, and patient decision support may encourage more men with favorable prostate cancer to feel comfortable in accepting this option.