'Era of Active Surveillance Has Arrived' in Prostate Cancer

Nick Mulcahy

May 16, 2015

NEW ORLEANS — The use of active surveillance for prostate cancer, once widely resisted by urologists, has been making gains in the United States and Europe, according to data presented here at the American Urological Association 2015 Annual Meeting.

The increases are impressive enough that one prominent urologist made a broad declaration: "The era of active surveillance has arrived," Stacy Loeb, MD, from New York University in New York City, told Medscape Medical News.

Some of the reported usage rates are unprecedented, she said during a meeting press briefing.

In a study that used 2013 data from the National Prostate Cancer Register of Sweden, Dr Loeb and her colleagues found a significant increase in the use of active surveillance of 78% for men with very-low-risk disease and of 59% for men with low-risk disease.

The rates are an improvement from just 2 years ago, she reported. In 2011 in Sweden, active surveillance was selected as primary management for 70% of very-low-risk and 47% of low-risk patients.

"The fact that they have achieved such high rates is amazing," she said during an interview.

The rest of the world should now look up to the Swedes, suggest Dr Loeb and her colleagues.

The fact that they have achieved such high rates is amazing.

"These data should serve as a benchmark upon which to compare the rates of active surveillance for favorable-risk disease around the world," they write in their meeting abstract.

Europeans have always been ahead of the Americans in adopting active surveillance, said Dr Loeb. But evidence presented at the meeting was also unprecedented in terms of usage rates in the United States, she added.

A separate retrospective study looked at 1401 men with prostate cancer newly diagnosed in 2013 at one of eight large urology group practices in the United States. Active surveillance was the primary therapy choice of 70.2% of men with very-low-risk disease and 39.2% of men with low-risk disease, reported Jeremy Shelton, MD, from Skyline Urology in Los Angeles.

"This is a report from the field and private practice urologists about how often they are using active surveillance," said Dr Shelton during the press briefing.

In another study of practice in the United States from 2008 to 2013, the primary treatment of 38.4% of men with low-risk tumors was watchful waiting or active surveillance, reported Matthew Cooperberg, MD, from the University of California, San Francisco.

The data come from CaPSURE, a prostate cancer registry that has been collecting data on men managed at 47 clinical sites, primarily community-based.

Level of risk was assessed using the CAPRA score. "Rates of overtreatment of low-risk prostate cancer remain high, but use of watchful waiting or active surveillance is increasing in a diverse cohort of men treated in US community practice," conclude the researchers.

Only 5 years ago, Dr Cooperberg's coauthor, Peter Carroll, MD, from the University of California, San Francisco, was very worried about the slow uptake of active surveillance by American urologists.

In 2010, only about 10% of all prostate cancer cases in the United States were managed with active surveillance, Dr Carroll said at the time, as reported by Medscape Medical News.

An estimated 40% of all newly diagnosed prostate cancers are candidates for active surveillance; that is the proportion of patients considered to have favorable risk (either very low or low).

Dr Carroll fretted that if urologists did not begin educating patients about active surveillance, they, as a profession, would have another professional debacle on their hands, comparable to the prostate-specific antigen (PSA) testing crisis.

"The controversy over PSA testing is now being played out in many mainstream venues, like the New York Times and the Wall Street Journal, and not necessarily urology publications," Dr Carroll said at that time.

Active surveillance is a way for clinicians to recover the use of PSA testing, suggested Dr Loeb. "It preserves the benefits of PSA testing but gets rid of overtreatment," she explained.

Large Urology Group Practice Association

In theretrospective study by Dr Shelton's team, the community-based urology practices were located in California, Colorado, Indiana, North Carolina, Ohio, Oregon, and South Carolina.

That study was initiated by a committee of the Large Urology Group Practice Association (LUGPA) in response to public "perceptions" about prostate cancer, said Dr Shelton.

Specifically, there are perceptions that prostate cancer management is "overly aggressive" and that there are "disincentives" for active surveillance, he explained.

Results from his team's study paint the LUGPA in a progressive light, which is in stark contrast to a previous study that depicted large urology groups as the center of the questionable practice of acquiring intensity-modulated radiation therapy services for the financial benefits of "self-referral" in the treatment of prostate cancer (N Engl J Med. 2013;369:1629-1637).

Dr Shelton explained that to be counted in his team's study, patients treated at large urology practices had to have a minimum of 6 months of documented follow-up from initial diagnosis. The average age of the men was 63.6 years, and the definitions of very-low-risk and low-risk prostate cancer were in accordance with National Comprehensive Cancer Network criteria.

Dr Loeb's study was funded was by the Swedish Research Council, the Swedish Cancer Foundation, and other sources. Dr Cooperberg has financial ties to Astellas; Dendreon; and Myriad Genetics. Dr Shelton and Dr Loeb did not complete disclosure forms.

American Urological Association (AUA) 2015 Annual Meeting: Abstracts MP4-03 (Shelton) and PD6-06 (Cooperberg), presented May 15, 2015; abstract MP42-10 (Loeb), to be presented May 17, 2015.


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