Active Surveillance Should Be Considered for Favorable-risk Prostate Cancer
For eligible men with favorable-risk prostate cancer, active surveillance should replace immediate intervention.
Men with favorable-risk prostate cancer have a low likelihood of harm from their diagnosis and should be encouraged to consider surveillance rather than curative intervention, a recent study published online ahead of print in the Journal of Clinical Oncology has shown.1
The American Cancer Society estimates that there will be about 220,800 new cases of prostate cancer in the United States in 2015, and about 27,540 patients will die from the disease. Despite the large number of cases each year, the relative 5-, 10-, and 15-year survival rates are about 100%, 99%, and 94%, respectively.2
Current National Comprehensive Cancer Network (NCCN) Guidelines for prostate cancer already recommend active surveillance for patients with low-risk prostate cancer expected to live another 10 to 20 years, as an option for patients with very low-risk disease expected to live 20 years or more, and as an option for patients with low-risk disease expected to live 10 years or more. Other options include external beam radiation therapy or brachytherapy, or radical prostatectomy with or without pelvic lymph node dissection.3
For the prospective study, researchers sought to evaluate long-term outcomes of men with favorable-risk prostate cancer receiving active surveillance.1
Researchers enrolled a total of 1,298 men (range, 41 to 92 years), of which 71% were diagnosed with very low-risk disease (clinical stage T1c disease, PSA density (PSAD) <0.15 ng/mL, biopsy Gleason score ≤6, 2 or fewer positive biopsy cores, and a maximum of 50% involvement of any biopsy core with cancer); 29% were diagnosed with low-risk cancer (clinical stage ≤T2a, PSA <10 ng/mL, Gleason score ≤6), with a median age of 66 years.
Patients were followed-up for a median of 5 years. Curative intervention was only recommended for patients who experienced disease reclassification to higher cancer grade or volume on prostate biopsy.1
Results showed that the 10-year overall, cancer-specific, and metastasis-free survival rates were 93%, 99.9%, and 99.4%, respectively, and 69%, 99.9%, and 99.4%, respectively, at 15 years.1
At 10 years, 50% of patients had undergone curative intervention, at 15 years, 57% of patients had. The median treatment-free survival was 8.5 years.1
“Our data suggest that, for men with favorable-risk prostate cancer, the paradigm of immediate intervention must be replaced by one of immediate contemplation—a thoughtful assessment of prognostic risk, life expectancy, and the relative risks and benefits of available management options considered in the context of personal preferences,” the authors concluded.1
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The question remaining, however, is when is the ideal time to stop active surveillance and initiate curative intervention? Other factors like age, health, ethnicity, and family history, with specific tumor characteristics, should be considered when making that determination.4
In an editorial accompanying Tosoian et al, Anthony D'Amico, MD, PhD, chief of the Division of Genitourinary Radiation Oncology at Brigham & Women's Hospital and Dana-Farber Cancer Institute in Boston, MA, stated that a validated “risk-group–based assessment scheme that incorporates both patient and cancer characteristics is needed to enable us to inform the individual man that his [prostate cancer], if left untreated, is likely or unlikely to metastasize during his remaining life expectancy.”4
- Tosoian JJ, Mamawala M, Epstein JL, et al. Intermediate and longer-term outcomes from a prospective active-surveillance program for favorable-risk prostate cancer [published online ahead of print August 31, 2015]. doi: 10.1200/JCO.2015.62.5764.
- Prostate Cancer. American Cancer Society website. http://www.cancer.org/cancer/prostatecancer/detailedguide/inind. Updated August 13, 2015. Accessed September 14, 2015.
- National Comprehensive Cancer Network (NCCN) Guidelines for Prostate Cancer. V 1.2015. http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Updated October 24, 2014. Accessed September 11, 2015.
- D'Amico AV. Personalizing the use of active surveillance as an initial approach for men with newly diagnosed prostate cancer [published online ahead of print August 31, 2015]. J Clin Oncol. doi: 10.1200/JCO.2015.63.6118.