Is Active Surveillance Best for Your Prostate Cancer Patient?

Howard Wolinsky

September 16, 2022

It may be safe for men older than 65 who have low-risk prostate cancer to go without active treatment, but for younger men with more advanced disease, a more aggressive approach should be considered.

That's the conclusion of a new study by researchers in Italy who found that the risk of death associated with low-risk prostate tumors was low for older men. The study was published September 14 in JAMA Network Open.

"Old men with low-risk PC [prostate cancer] had a long time without active treatment and [a] low risk of PC death, whereas young men with intermediate-risk PC had little benefit" from active surveillance, write lead author Eugenio Ventimiglia, MD, of IRCCS Ospedale San Raffaele, a research hospital and university in Milan, Italy, and his colleagues.

The large study of Swedish men who opted not to undergo treatment of prostate cancer showed that active surveillance was safe for those older than 65 who had low-risk lesions. Men younger than 65 who had intermediate-risk prostate cancer faced a higher risk of death and a decreased life span.

Samuel L. Washington III, MD, assistant professor of urology, epidemiology, and biostatistics at the University of California, San Francisco ― which pioneered active surveillance in the United States ― agreed with the first recommendation concerning older men but not with the second concerning younger men.

"The researchers are basically saying that younger patients [with intermediate-risk disease] should go on to treatment, rather than active surveillance," Washington, who was not involved in the study, said.

Other studies have shown that active surveillance ― a protocol in which patients are monitored with tests and digital exams and, in more recent years, MRIs and biopsies ― is safe for younger patients. But success depends on careful patient selection, workup, and testing, Washington added.

"It's still debated but has been shown to be safe in our cohort," Washington said.

Nearly 24,000 Men

Ventimiglia and his colleagues analyzed data from 23,655 men who had been diagnosed with prostate cancer and who deferred treatment between 1994 and 2014. The data were from the PCBaSe Sweden database.

In addition to surgery and radiotherapy, patients with other life-threatening illnesses or who were too old to benefit from treatment had the option of watchful waiting. If patients chose this route, they observed their own symptoms and informed their doctor of any changes.

Treatment trajectories were estimated using a model based on age at diagnosis, prostate cancer risk category, level of prostate-specific antigen, the Charlson Comorbidity Index, and a patient's cancer risk until age 85 or risk determined at follow-up 30 years after diagnosis.

The median age at diagnosis was 69 years (interquartile range, 64–74 years). A little more than 16,000 men underwent active surveillance, and 7478 underwent watchful waiting. The proportion of men who were diagnosed at age 55 years and who died of prostate cancer before age 85 years was 9% for those with very low-risk tumors, 13% for those with low-risk cancers, and 15% for those with intermediate-risk disease.

"These results may be useful in informing clinical practice with regard to disease management and follow-up of men with prostate cancer regarding the optimal selection of treatment strategies and their allocation to patient populations that will benefit most from their implementation," writes Ahmed Elmehrath, MD, of the faculty of medicine at Cairo University in Egypt, in an editorial that accompanied the journal article.

But Washington said the new findings will not change his treatment of this patient population and that the study "underestimates the benefit of delaying potential side effects of treatment," including those associated with surgery and radiotherapy.

Sweden now leads the world in active surveillance for low-risk prostate cancer, with more than 90% of patients nationally choosing the option, compared with 60% of patients in the United States.

Most active surveillance cohorts are just now reaching 15 to 20 years of follow-up, making longer-term survival difficult to estimate, Washington noted. "We simply don't have long enough follow-up, particularly as active surveillance continues to incorporate additional testing and technology," he said.

New technology includes genomic testing, multiparametric MRI, and MRI fusion biopsy, he said. Ventimiglia and his colleagues acknowledge that data from recent years are likely more robust because of the use of the enhanced diagnostic techniques.

"When men have less than a 10-year life expectancy, it's worth questioning whether they need continued active surveillance in its true form, vs deescalation of intensive serial monitoring," Washington said. "While we don't have a clear universal stopping point, the question does highlight the importance of shared decision-making with the patient and candid discussion of life expectancy, quality of life."

The study authors and Washington have reported no relevant financial relationships.

JAMA Network Open. Published September 14, 2022. Full text, Editorial

Howard Wolinsky is a Chicago-based medical journalist. You can read more of his stories about prostate cancer at TheActiveSurveillor.com.

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