Active Surveillance for Prostate Cancer: is it for you?

The decision facing many blokes upon diagnosis of prostate cancer is difficult. Should you opt for surgery, some other treatment or simply monitor the numbers and hope it stays stable or slow growing. The research reported below may help you in your decision. At least it gives you some background when discussing your best options with your urologist and GP.

STOCKHOLM—Active surveillance (AS) for patients with favorable risk prostate cancer (PCa) is safe long-term, with patients much more likely to die from causes other than PCa, according to study findings presented at the European Association of Urology 29th annual congress.

The study, led by Laurence Klotz, MD, of Sunnybrook Health Sciences Centre, University of Toronto, included 993 men (median age 67.8 years) with favorable or intermediate PCa who underwent AS for a median of 8.1 years. A total of 206 men were followed for more than 10 years and 50 were followed for more than 15 years.

Of the 993 men, 149 died (15%), 15 (1.5%) from PCa. The 10- and 15-year actuarial cancer-specific survival rates were 98.1% and 94.3%, respectively. Patients were 9.2 times more likely to die from other causes than from PCa.

In addition, at 5, 10, 15, and 20 years, 75.7%, 63.5%, 55.0%, and 55.0%, respectively, remain untreated and on AS. Metastatic disease developed in an additional 7, who either died of other causes (5) or are alive with disease (2). Post-treatment failure occurred in 6.3% of the total cohort.

“Active surveillance for favorable risk prostate cancer is feasible and appears safe in the 15-20 year time frame,” the authors concluded in their poster presentation.

At entry into AS, patients had a Gleason score of 6 (or 7 for men aged 70 and older), clinical stage T1b-T2b N0 M0, and a PSA level of 10 ng/mL (15 or less in men aged 70 or older). All had elected to be managed with AS. Clinicians offered intervention to patients if they had  Gleason score progression, a PSA doubling time of less than 3 years, or unequivocal clinical progression.

Although AS may be a safe option, a study published recently in the New England Journal of Medicine (2014;370:932-942) found that men with localized PCa are less likely die from the disease if they undergo radical prostatectomy (RP) instead of watchful waiting, especially if they are younger than 65 years. At 18 years of follow-up, RP was associated with an overall significant 44% decreased risk of death from PCa compared with watchful waiting. Men younger than 65 years had a significant 55% risk reduction, whereas older men had a non-significant 25% decreased risk.

Dr. Klotz told Renal & Urology News that the patients on the watchful waiting arm of this study did not have serial biopsies or the opportunity for delayed definitive therapy upon risk reclassification. In addition, most of the patients who died from PCa had intermediate- or high-risk disease at diagnosis.