COMMENTARY

Does Active Surveillance Increase Risks in Younger Men With Prostate Cancer?

Gerald Chodak, MD

Disclosures

October 04, 2018

Hello. I am Dr Gerald Chodak, for Medscape. Today I will be discussing whether offering active surveillance to younger men poses an added risk.

Mahran and colleagues[1] conducted a meta-analysis of studies [on active surveillance of prostate cancer] that were published between 1980 and 2017. They specifically looked at reports that reported data on repeat biopsies according to age. This involved about 6100 papers, of which eight met the criteria set out for inclusion. Those eight studies involved 6522 men between the ages of 41 and 86 years. The investigators looked at the data in two ways: increases in Gleason scores on follow-up biopsy (biopsy progression), and either an increase in Gleason score or an increase in tumor volume (Gleason upgrading).

They found that younger men had a significantly lower risk for disease progression compared with older men. For each decade less in age, the men had a 13%-17% lower risk for Gleason score upgrading and a 12%-20% percent lower risk for pathologic progression defined by Gleason score or tumor volume. Thus, a man in his 50s has a 26%-34% lower risk for disease progression than a man in his 70s, who's on active surveillance.

The analysis did have some limitations. Follow-up was relatively short, at 1.6-6.5 years. Also, the authors did not specifically report the pathologic findings of men who underwent definitive therapy because of biopsy progression. Nevertheless, this study does tell us that it appears that younger men do not have a greater risk for disease progression.

Arguments can be made that offering active surveillance to younger men may have a more positive impact on quality of life, because younger men are more likely to have good sexual and urinary function. Thus, if they were to undergo treatment and risk losing or compromising those functions, that would have a greater negative impact on their quality of life compared with the impact of treatment in older men. On the other hand, some may argue that there may be a greater risk by not curing them when they are younger because they have a longer time to live. So far, other studies have shown that this is not the case and that men who are younger and have progression don't appear to have a worse outcome compared with older men. But that was not addressed in this report.

The bottom line is, offering active surveillance to men who are younger and have a lower-risk or very-low-risk tumor certainly seems reasonable. This may also be the case for men with intermediate-risk disease.

I look forward to your comments. Thank you.

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