There is no wide consensus about age, tumor grade, tumor volume, or prostate-specific antigen (PSA) threshold criteria for identifying which patients would be best served by watchful waiting and which should be recommended for active surveillance, noted Dr Chapin.
“Generally, strict age cut-offs are not used in clinical practice as there are many men in their 70s who are physiologically much younger and vice versa,” he explained.
“Although national guidelines committees have outlined eligibility criteria for active surveillance and watchful waiting for prostate cancer, variability exists across institutions and physicians,” said Behfar Ehdaie, MD, MPH, a surgical oncologist at Memorial Sloan Kettering Cancer Center in New York, New York.
Memorial Sloan Kettering Cancer Center has developed a life expectancy calculator to assist in treatment and surveillance decision-making.
Among other challenges, African American men with low-risk prostate cancer are less likely to receive active surveillance than Caucasians, according to authors of an analysis.6
African American patients “often defaulted to de facto watchful waiting after an initial period of active surveillance,” with 58% undergoing no active surveillance, compared to 37% of white men (P < .0001), the authors reported.
“African American men were more likely to receive only 1 of the 3 recommended components of active surveillance, compared with Caucasian men,” said senior study author Badrinath Konety, MD, MBA, chair of the department of urology at the University of Minnesota in Minneapolis.
“Furthermore, African American men were grossly underrepresented, making up only 10.5% of our study cohort, suggesting either lower awareness and/or lower rates of adoption of conservative management strategies,” Dr Konety told Cancer Therapy Advisor. “We did, however, notice an encouraging upward trend in uptake of active surveillance among African American men (9.7% in 2004 to 15.5% in 2009), suggesting more awareness and adoption of alternative management modalities such as active surveillance.”
That might be partly due to concern that African American men have both a greater risk of prostate cancer and a more aggressive prostate tumor biology than reported for men in other ethnic or racial groups.
Nevertheless, Dr Chapin believes that close monitoring with surveillance “can be an appropriate option for African American men.”
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“Many believe [these outcomes disparities are] more related to socioeconomic status and less to specific race or ethnicity. Men with higher income, health insurance, and education tend to follow up with their primary care physicians and have PSA screening, in addition to seeking out second opinions for their treatment options once prostate cancer is diagnosed.”
The decision to offer patients active surveillance is based primarily on clinical and pathologic characteristics, though this may change.
“The role of biomarkers, family history of prostate cancer, and ethnicity are still understudied, though advances in genomics provide an opportunity to individualize risk and enable better decision-making,” Dr Ehdaie said.
For now, hope for “liquid biopsies” to identify which patients should undergo immediate treatment, active surveillance, or watchful waiting is not realistic.
“I think that liquid biopsies are very exciting but most of the [current] research is for patients who have pretty advanced cancers,” Dr Chen explained. “That’s the type of patient in whom they’re able to get some circulating tumor cells. With active surveillance, we’re talking about very, very early-stage prostate cancer. I am not sure the technology is where we need it to be to detect the cancer from circulating cells at this point.”
- Stavrinides V, Parker CC, Moore CM. When no treatment is the best treatment: active surveillance strategies for low-risk prostate cancers. Clin Treat Rev. 2017;58:14-21.
- Morash C, Tey R, Agbassi C, et al. Active surveillance for the management of localized prostate cancer: guideline recommendations. Can Urol Assoc J. 2015;9(5-6):171-8. doi: 10.5489/cuaj.2806
- Chen RC, Rumble RB, Loblaw DA, et al. Active surveillance for the management of localized prostate cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology Clinical Practice Guideline endorsement. J Clin Oncol. 2016;34(18):2182-90. doi: 10.1200/JCO.2015.65.7759
- Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375(15):1415-24. doi: 10.1056/NEJMoa1606220
- Saad F. Screening and treatment: where do we go from here? Nat Rev Clin Oncol. 2017;14(1):7-8. doi: 10.1038/nrclinonc.2016.189
- Krishna S, Fan Y, Jarosek S, Adejoro O, Chamie K, Konety B. Racial disparities in active surveillance for prostate cancer. J Urol. 2017;197(2):342-9. doi: 10.1016/j.juro.2016.08.104