Five Obstacles to Active Surveillance in Three Cancers

Nick Mulcahy

July 19, 2017

Active surveillance (AS) has become a buzzword in oncology and is already being used in clinical practice for low-risk prostate cancer and in clinical trials for low-risk thyroid cancer. It has also been discussed for the lowest-risk breast cancer, ductal carcinoma in situ (DCIS).

AS is desirable in all three cancers because of obvious overtreatment, which is costly for patients (including injurious side effects) and for the healthcare system, say the authors of a new essay.

Forbiddingly, however, the three cancers (and their AS champions) will have to go through a long-winding obstacle course to get to the finish line of widespread and successful AS use, they suggest. The successful  uptake of this approach "will require overcoming perceived challenges to implementation," they write.

The essay was published in the July 20 issue of the New England Journal of Medicine

There are five major obstacles, write Megan R. Haymart, MD, an endocrinologist, David C. Miller, MD, a urologist, and Sarah T. Hawley, PhD, a cancer prevention researcher, all from the University of Michigan in Ann Arbor.

Obstacle 1: Defining AS

This includes defining which imaging and other monitoring tools to use and  how long  AS should be continued. Overall, a lot of work needs to be done here because "there are currently no clear guidelines" — even for AS for prostate cancer, which is already used in practice.

The authors highlight thyroid cancer in this section of their essay, saying AS likely includes periodic neck ultrasonography and testing of the tumor marker serum thyroglobulin. But this is tricky: "The reliability of neck ultrasound findings depends on the skill of the physician performing and reading the ultrasound,"  the authors say.

There is a further challenge: "It's still not clear how thyroglobulin measurements should be interpreted in patients who have an intact thyroid, since thyroglobulin is made by both normal thyroid tissue and thyroid cancer cells."

In the case of DCIS, optimal surveillance  includes mammography, "but the ideal frequency of imaging and whether additional tests or biopsies are necessary remain unknown."

Obstacle 2: Getting Physician and Patient Buy-in

This is happening in prostate cancer, point out the authors, and is facilitated by the fact that a single group of clinicians — urologists — are responsible for AS.

There is a similar clarity about management of thyroid cancer because  endocrinologists are in charge. But this obstacle may be especially challenging for DCIS because it is not clear who should manage AS here — primary care physicians, surgeons, or medical oncologists?

Essay author Dr Hawley said this need for leadership is a key to uptake of AS for DCIS.

"Surgeons likely do not have the ability to be the gatekeeper for managing AS — in terms of time, but also in terms of reimbursement," she said in an email to Medscape Medical News. "Primary care physicians may be able to manage patients with DCIS with AS. But they have not typically been in this role and would need education and training."

Whoever is in charge should "make sure patients understand the data," said Michael Stefanek, PhD, a psychologist at Augusta University in Georgia and a member of the Georgia Cancer Center, who was not involved with the essay.

"We should stay away from relative risk information," Dr Stefanek  told Medscape Medical News. Instead, data on survival, adverse events, and other important benchmarks should be presented in absolute terms, he emphasized.

Opting for active surveillance is driven by a range of factors, including patient values, physician endorsement, perceived risk for cancer, treatment options, and "transparent" data, summarized Dr Stefanek.

Obstacle 3: Identifying Appropriate Patients

Among the challenges here is patient age, say the authors. The median age at diagnosis among patients with prostate cancer is 66 years. Given the life expectancy for US men, this is a relatively manageable window of time. On the other hand, patients with low-risk thyroid cancer are 51 years old at diagnosis. Among other things, that means much longer follow-up; moreover, younger age at diagnosis is a risk factor for more aggressive thyroid cancer, the Michigan trio points out.

Obstacle 4: Maintaining Surveillance

Some percentage of men with prostate cancer are lost to follow-up or don't undergo recommended monitoring with biopsies, prostate-specific antigen testing, and other tests, as reported by Medscape Medical News. This challenge is also likely to exist for thyroid cancer and DCIS. The "common concern" here for all three cancers is that "cancer progression may go unrecognized," say the authors.

Obstacle 5: Addressing Patient Anxiety

"Active surveillance is unlikely to eliminate the worry associated with a cancer diagnosis," write the authors. Worry is associated with the decision among patients with prostate cancer on AS to opt for treatment, as reported by Medscape Medical News  "Tailored support tools to reduce worry during active surveillance" will need to be created, say the essay authors.


Approached for comment, Dr Stefanek said that the new essay is a good, broad roadmap for "what is needed to move forward, including how to actively follow" each type of patient.

"As the authors note, different questions need to be addressed with each diagnosis, with most work in the area of thyroid cancer. What is needed does indeed include not just individual variables (eg, fear) but also societal/insurance issues (who covers what and how often)," he added.

The authors have disclosed no relevant financial relationships.

N Engl J Med. 2017;377:203-206. Abstract

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