Careful patient selection for active surveillance reduces treatment need
MedWire News: Prostate cancer patients are unlikely to require definitive treatment after undergoing active surveillance if they are selected on the basis of strict low-risk criteria, suggest US researchers.
"If guidelines for [active surveillance] are narrowly defined to include only patients with Gleason 6 tumors, tumor volume 20% or less in one or two biopsy cores, and PSA [prostate-specific antigen] levels of 10 ng/ml or less, few patients are likely to require treatment," say Mark Soloway and colleagues from the University of Miami Miller School of Medicine in Florida.
To encourage more low-risk patients to consider active surveillance as an alternative to early curative therapy, which can adversely affect health-related quality of life (HRQoL), the researchers investigated how best to follow low-risk patients undergoing a watchful waiting strategy, and what percentage went on to receive definitive treatment.
A cohort of 230 patients with biopsy-confirmed prostate cancer who met the low-risk criteria for active surveillance were followed-up for a mean duration of 44 months.
The men underwent PSA measurements and rectal exams every 3 to 4 months for 2 years, and every 6 months thereafter. In addition, targeted biopsies were carried out 9-12 months after the initial diagnosis and then annually, or earlier if the patient experienced a dramatic PSA rise or had an abnormal rectal exam.
After the first repeat biopsy, 50% of patients remained tumor-free, and only 5% of these went on to be treated during follow-up. After the second, third, and fourth repeat biopsies, no tumors were present in 49%, 52%, and 71% of patients, respectively.
Interestingly, PSA doubling time and clinical disease stage were not predictors for requiring treatment, say Soloway et al in the journal European Urology.
In all, 86% of the cohort remained under active surveillance during a mean follow-up of 33 months, with 32 (14%) patients requiring treatment with surgery (n=12), radiotherapy (n=14), or androgen deprivation therapy (n=6). No patients experienced disease progression after treatment, or died of prostate cancer.
Of the 172 patients who completed the International Conference on Incontinence Short Form, 30% reported a degree of incontinence but few were bothered by it. Similarly, the results of the Sexual Health Inventory for Men indicated 49% had moderate erectile dysfunction.
With careful selection of low-risk patients, "the dilemma regarding overtreatment and its impact on HRQoL, which may already be impaired at diagnosis, may be less - if and when [active surveillance] is accepted as a viable alternative," conclude the researchers.
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By Sarah Guy