Active Surveillance of Untreated Early Prostate Cancer: A Solution to Patient Anxiety?

Nick Mulcahy

July 29, 2009

July 29, 2009 — Anxiety and prostate disease seem so intertwined that one expert notes that some clinicians say that PSA stands for "prostate-specific anxiety."

Anxiety can be particularly acute in men who are diagnosed with early prostate cancer but who are not treated with surgery or radiation. A new study from the Netherlands that addressed this issue, published online July 27, 2009 in Cancer, suggests that active surveillance can ameliorate some of this anxiety. The findings might also help to optimize patient selection for active surveillance, the authors suggest.

"Active surveillance is different from the more traditional 'watchful waiting' option, in that the aim of the latter (i.e., optional deferred treatment) is purely palliative," write the authors, led by Roderick van den Bergh, MD, from the Erasmus Medical Center in Rotterdam, the Netherlands. The term active surveillance suggests a curative aim, the authors add.

In addition, they note that "active surveillance is emerging as a realistic strategy to avoid overtreatment by surgery or radiation therapy."

However, an expert in prostate cancer and anxiety approached by Medscape Oncology for outside comment noted that the value of the study's findings are limited by a number of factors, including the fact that these men were not likely to be anxious in the first place because they had elected to be in the study.

A Self-Selected Group

The 129 men in the study are participants in the Dutch section of the ongoing international prospective observational Prostate Cancer Research International: Active Surveillance (PRIAS) study, which will evaluate outcomes with this approach to early prostate cancer.

The active-surveillance protocol in PRIAS calls for preplanned doctor visits every 3 months for a prostate-specific antigen (PSA) test, a digital rectal exam every 6 months, and repeat biopsies — the first at 1 year from diagnosis and others at specific intervals thereafter.

Dr. William Dale

The investigators surveyed the participants about their feelings regarding their prostate cancer. After being in the active-surveillance program for an average of about 2 months, the men responded to a questionnaire, which showed that 83% and 93%, respectively, scored better than the reference values for generic anxiety and prostate-cancer-specific anxiety.

These results led the investigators to conclude that "men on protocol-based active surveillance mainly reported favorable levels of anxiety and distress."

However, an expert in anxiety and prostate cancer questioned the value of this finding.

"All of the men had chosen to be in the active-surveillance program," said William Dale, MD, from the geriatrics and palliative medicine and hematology/oncology sections at the University of Chicago in Illinois.

"These men have been self-selected, and they are going to be satisfied with active surveillance as a treatment strategy, and therefore not anxious," Dr. Dale opined.

How many highly anxious men avoided the surveillance [and the study] and had active treatment? That should be reported here.

"How many highly anxious men avoided the surveillance [and the study] and had active treatment? That should be reported here," he added.

Despite his reservations, Dr. Dale believes the study is helpful to clinicians in a number of ways, including its use of the term active surveillance instead of watchful waiting.

Active surveillance is a term that can inspire confidence in patients, suggested Dr. Dale.

I think active surveillance is much better than the former term, "watchful waiting.

"I think active surveillance is much better than the former term, 'watchful waiting.' Laying out a strategy for monitoring the disease regularly and checking with biopsies is a good approach. It is much different than simply 'waiting' for something to happen," he told Medscape Oncology.

Choosing Patients for Active Surveillance

The new study shows that surveillance can be used with minimal psychological morbidity in properly selected patients with low-grade, low-volume, localized prostate cancer, summarized Dr. Dale.

Men were eligible for the PRIAS study if they had a diagnosis of adenocarcinoma of the prostate with a PSA level of 10 ng/mL or less, a PSA density of less than 0.2 ng/mL per mL, nonpalpable or localized disease, no more than 2 positive prostate needle-biopsy cores, and a Gleason score of 6 or more.

In this early evaluation of the feelings of 129 men enrolled in the study who answered a questionnaire, a number of factors were associated with unfavorable scores. In addition to evaluating generic anxiety and prostate-cancer-specific anxiety, the investigators gauged depression and decisional conflict in the patients.

The patients' perceptions of the physician as overly influential in the shared treatment decision-making, a poor physical health score, a high neuroticism score, and a high PSA value all had significant positive associations with all 4 psychological categories being evaluated, including generic anxiety and prostate-cancer-specific anxiety.

"Awareness that patient-related factors are associated with levels of anxiety and distress may be useful in the shared treatment decision-making process in general or in the selection of patients for active surveillance," note the study authors.

The study was supported by the Prostate Cancer Research Foundation (SWOP) of Rotterdam, the Netherlands. The researchers have disclosed no relevant financial relationships.

Cancer. Published online before print July 27, 2009. Abstract

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