COMMENTARY

Active Surveillance for PCa: Popular but Not Perfect

Gerald Chodak, MD

Disclosures

May 05, 2016

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Hello. I'm Dr Gerald Chodak for Medscape.

Today I want to talk about an interesting review article by Tosoian and colleagues[1] who discuss the current status of active surveillance for prostate cancer. The clear evidence is that active surveillance is gaining in popularity around the world, with the United States leading the charge and other countries, such as Australia, Canada, Sweden, and Germany, following suit. The only country that seems to be lagging behind in acceptance is Japan.

Over the years there has been a growing percentage of men and doctors who are embracing this form of therapy. In the United States, a significant proportion of men with low-risk disease were being offered this between 2010 and 2014.

Selecting the right group of patients for active surveillance is one issue. One of the most important criteria has been Gleason score, but others include prostate-specific antigen density, number of cores positive, and whether or not there is presence of Gleason 4 pattern cancer. Some studies have actually incorporated Gleason 3 + 4 disease into the inclusion criteria; long-term outcomes are still lacking.

Another challenge is, how do you monitor men who decide to go on active surveillance? Clearly, biopsy has been a mainstay of management, with many places recommending a biopsy within the first 2 years and subsequent biopsies 1-4 years later. There are reasons for concern about extensive biopsies over time. Recognition is growing that complication rates from biopsies are not insignificant and are not declining. This is an issue to contend with going forward.

Another issue is age. Should younger men with a life expectancy of 15 or more years be offered this therapy? What about African American men? There are few data to help us know whether it is as safe for African American men with low-risk disease as it is for Caucasian men. Further data are needed.

Another limitation is the long-term follow-up. Using Kaplan-Meier projections, in 5-7 years and maybe up to 10 years, the incidence of metastatic disease and death remains low. But we need much more mature data before we can tell people exactly what to expect if they take this approach. Clearly it has the implications that, for younger men, the long-term risks are still unclear.

Other things are being looked at as we go forward. Parametric MRI is being looked at to help monitor men and perhaps reduce the number of prostate biopsies. Urinary markers and genetic tests are also being looked at to help decide when treatment is necessary. These things remain variables among the different centers offering the treatment.

Active surveillance clearly has taken a real foothold. We can tell men that after about 5 years, somewhere between 25% and 40% will get treated—meaning that somewhere between 60% and 75% are able to avoid treatment, at least for that period of time. While it certainly isn't a guarantee that they will have a safe outcome, the incidence of metastatic disease and mortality is extremely low.

Selecting when to get treated is going to remain a very critical part of deciding the balance between not waiting too long and not rushing to treat too soon. The bottom line is, surveillance clearly has gained in popularity and is becoming more accepted to both doctors and patients. It is a way to wade through the balance of harms vs benefit for a disease that has such a variable outcome.

I look forward to your comments. Thank you.

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