The National Comprehensive Cancer Network (NCCN) recently updated its guidelines for the treatment of prostate cancer,1 and one change has some physicians concerned.2,3

The updated guidelines no longer say that active surveillance is “preferred” for low-risk prostate cancer, and some physicians have suggested that this change may encourage overtreatment.

“The fact that the NCCN actively went from saying ‘surveillance preferred’ back to implying that active surveillance, surgery, and radiation are equivalent options is backtracking,” said Matthew Cooperberg, MD, a professor of urology at the University of California, San Francisco.

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“It’s a step in the wrong direction, and there’s no clear rationale for it in the guidelines text,” he added.

Avoiding Overtreatment

Unlike the new NCCN guidelines, American Urological Association guidelines4 advise clinicians to “recommend active surveillance as the preferable care option for most low-risk localized prostate cancer patients.”

Active surveillance typically involves frequent prostate-specific antigen (PSA) testing, digital rectal exams, and sometimes prostate biopsies, genomic testing, and further imaging.5 The goal of active surveillance is to monitor the cancer for changes and only explore treatment options when needed, as treatment can negatively impact patients’ quality of life.

“We as a treating community overtreated low-risk prostate cancer far too often, and we’ve made a lot of progress in the last 5 to 10 years, with more men being put on active surveillance,” Dr Cooperberg said. “It’s not as high as it should be, but it’s progress in the right direction.”

“For low-risk disease, there are always some situations where early, more immediate treatment is justified, but this is probably significantly less than 20% of men with low-risk disease,” Dr Cooperberg added.

“What we know at the end of the day, from a number of studies, is the likelihood of getting active surveillance with low-risk prostate cancer ranges from 0% to 100%, depending on which clinician’s door you happen to knock on with your prostate cancer diagnosis,” he continued. “That’s a big problem.”