Prostate Cancer: 'Active' Surveillance Is Often 'Not'

Kate Johnson

May 09, 2016

SAN DIEGO, California — Only 1 in 3 men with low-risk prostate cancer receive appropriate follow-up when assigned to active surveillance (AS) of their disease, a new study suggests.

The findings add to a growing body of evidence that suggests that prostate cancer risk may be higher than expected in this population of men categorized as having low-risk disease.

Under AS, both patients and providers "may have a tendency to get a little lackadaisical," study investigator Gregory Auffenberg, MD, from the University of Michigan, in Ann Arbor, told Medscape Medical News.

The result may be a "potentially higher risk than what we all agreed on ― and what patients thought they were getting into ― when we embarked on the surveillance pathway."

The findings, presented here at the American Urological Association (AUA) 2016 Annual Meeting, point to biopsies as the main missing link.

"Biopsies are not comfortable, they're not risk-free, and patients don't like them," he said.

But it is likely that provider factors also contribute to suboptimal AS.

Guidelines for AS "are not crystal clear," but a conservative estimate is that men should undergo repeat prostate specific antigen (PSA) testing roughly every 6 months and should undergo a repeat biopsy every 2 years, said Dr Auffenberg.

To assess compliance with this, his study analyzed AS in 431 men with low-risk prostate cancer who were followed for at least 2 years.

The patients, from the Michigan Urological Surgery Improvement Collaborative database, were followed by 232 Michigan urologists from 42 practices.

The median age of the men was 66 years, and the median PSA level was 5.3 ng/ml at baseline. A total of 75% of the patients had a biopsy Gleason Score of ≤6, and 17% had Gleason 3+4 disease.

Between January 2012 and September 2013, fewer than one third (30.6%) of the cohort received guideline-concordant care, defined as one biopsy and three PSA measurements.

Among the remaining 69.4% of patients who received guideline-discordant care, biopsy represented the biggest gap; 53.6% of patients received either no biopsy (31.3%) or no PSA test (15.8%), and 22.3% receiving neither.

"Active surveillance involves an up-front agreement between the provider and patient. It does not mean 'forget about it,' " said Dr Auffenberg.

"It means you have cancer, and we're going to actively follow it. It's a management strategy, and biopsy is really the gold standard to have a really good idea of what's going on in the patient's cancer."

Asked to comment on the findings, Scott Eggener, MD, codirector of the Prostate Cancer Program at the University of Chicago Medical Center, told Medscape Medical News, "A lot of men with prostate cancer on active surveillance ultimately end up being followed by a nonurologist, and unfortunately, information on appropriate follow-up understandably isn't known amongst the primary care community."

He said that although some of the missed follow-up is patient driven ― "they just stop showing up, and they get too comfortable" ― there are also physicians who "undoubtedly are not following or recommending the guidelines and probably aren't ordering the tests or biopsies perhaps as regularly as they should."

Stacy Loeb, MD, a prostate cancer specialist from New York University and member of the AUA Public Media Committee, told Medscape Medical News that the findings are consistent with those from a study her group conducted, which employed use of the SEER-Medicare database.

"We found very similar results ― namely, that very few men are actually receiving the intensity of follow-up that is used in major prospective active surveillance programs, with the rates of follow-up prostate biopsy being particularly low. One of the key questions that remains unanswered is, what is the optimal protocol to use for active surveillance? Now that more men are choosing active surveillance, we must focus more efforts on identifying the best testing protocol for specific patient populations and ensuring sufficient follow-up."

Dr Auffenberg, Dr Eggener, and Dr Loeb have disclosed no relevant financial relationships.

American Urological Association (AUA) 2016 Annual Meeting: Abstract MP25-12, presented May 7, 2016.

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