ASCO Endorses Active Surveillance for Prostate Cancer

Nick Mulcahy

March 03, 2016

The American Society of Clinical Oncology (ASCO) now recommends active surveillance instead of immediate treatment for most men with low-risk prostate cancer.

The recommendation comes by way of an endorsement of guidelines from Cancer Care Ontario, which was published online February 16 in the Journal of Clinical Oncology.

"There is an increasing awareness that active surveillance is an important approach to spare many prostate cancer patients from treatment that they don't need and that can cause lasting quality-of-life effects," lead author of the endorsement, Ronald C. Chen, MD, MPH, from the University of North Carolina Lineberger Comprehensive Cancer Center in Chapel Hill, said in a press statement.

Other organizations have recommended active surveillance for some time. The National Cancer Comprehensive Network (NCCN) led the way in 2010, recommending active surveillance as the sole management option for low-risk prostate cancer. Recently, the NCCN expanded its recommendation to include favorable intermediate-risk prostate cancer.

Estimates vary on how common active surveillance is in the United States. In 2010 and 2011, just 12.1% of men with very low-risk prostate cancer were treated with active surveillance, according to one study (JAMA Intern Med. 2015;175:1569-1571). However, another study showed that 38.4% of men with low-risk disease were treated with either active surveillance or watchful waiting.

Recommendations in the Endorsement

In their endorsement, the ASCO team made some modifications to the Canadian guidelines, explained senior author Suneil Jain, MB, PhD, who is now a radiation oncologist at Queen's University Belfast in Northern Ireland.

Dr Jain and his coauthors state that "for most patients with low-risk (Gleason score 6) localized prostate cancer, active surveillance is the recommended disease management strategy."

However, they add a qualifying statement to the Canadian guidance: "It is known that there is heterogeneity within this population and therefore factors such as younger age, high-volume Gleason 6 cancer, patient preference, and/or African American ethnicity should be taken into account in this recommendation. Young patients (younger than age 55 years) with high-volume Gleason 6 cancer should be closely scrutinized for the presence of higher-grade cancer, and definitive therapy may be warranted for select patients."

These patients have a "higher likelihood for disease progression during their lifetime," the authors report.

The ASCO team does "not wish to indicate that patients with the above factors should not be considered for active surveillance," but that clinicians and patients should keep the risk for disease progression in mind when making a decision, Dr Jain told Medscape Medical News.

Select patients with low-volume, intermediate-risk (Gleason 3 + 4 = 7) prostate cancer can be offered active surveillance, according to the endorsement.

However, active treatment (radical prostatectomy or radiation therapy) is recommended for most patients with intermediate-risk (Gleason score 7) localized prostate cancer, the ASCO team writes.

Active surveillance protocols should include prostate-specific antigen testing (every 3 to 6 months), digital rectal examinations (at least every year), and serial prostate biopsies. At the least, the biopsy should be a 12-core confirmatory transrectal ultrasound-guided procedure (including anterior directed cores) within 6 to 12 months, and then serial biopsy every 2 to 5 years thereafter.

Investigational ancillary radiologic and genomic tests could be used in patients with discordant clinical and/or pathologic findings, the report indicates.

Patients who are reclassified to a higher-risk category (Gleason score ≥7) or who have significant increases in tumor volume on follow-up biopsies should be offered active therapy, the authors state.

The ASCO team does not endorse any specialty as being best suited to manage active surveillance, but does say that a "multidisciplinary team approach should be taken when a change to active treatment is considered."

Dr Chen reports financial ties to Medivation/Astellas Pharma. Dr Jain reports financial ties to Janssen-Cilag, Ferring Pharmaceuticals, and Astellas Pharma. Some of the other authors report ties to industry, as detailed in the publication.

J Clin Oncol. Published online February 16, 2016. Full text

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