Conservative management increasing in younger prostate cancer patients
medwireNews: Rates of active surveillance or watchful waiting (AS/WW) among younger men with low‐risk prostate cancer have quadrupled in recent years but remain below those for older men, despite no apparent increased mortality risk, research shows.
“Management for men aged ≤55 years with low‐risk prostate cancer […] is debated given quality‐of‐life implications with definitive treatment versus the potential missed opportunity for cure with conservative management,” write Brandon Mahal (Dana-Farber Cancer Institute, Boston, Massachusetts, USA) and co-authors in Cancer.
They add: “On the basis of the results of this study, it appears that clinicians and patients feel AS/WW is a reasonable alternative to definitive treatment for low-risk disease, resulting in an increasing preference toward AS/WW across age groups.”
The study included data for 50,302 men who were diagnosed with low‐risk prostate cancer (stage T1–T2a, Gleason score 6, and prostate-specific antigen level <10 ng/mL) in the USA between 2010 and 2015. Of these, 19.8% were aged 55 years or younger at the time of diagnosis.
The researchers report that AS/WW utilization increased significantly over time regardless of age, rising from 8.6% in 2010 to 34.6% in 2015 among men aged 55 years and younger and from 16.0% to 43.8% among those aged 56 years and older.
Nonetheless, they also point out that, overall, radical prostatectomy (RP) remained the most common initial management strategy among younger men, with a 48.4% utilization rate at the end of the study period.
Regardless of age, AS/WW was the most common treatment approach used by 2015 in men with very low-risk disease (up to two positive biopsy cores), with rates increasing significantly from 12.9% to 48.8% in the younger men and from 21.9% to 58.0% in the older age group.
Significant increases in AS/WW rates over time were also seen in the patients who had three or more positive biopsy cores, rising from 3.9% to 22.5% for men aged 55 years and younger and from 10.1% to 28.5% for men aged 56 years and older, but the investigators note that RP remained the favored initial treatment for these patients in both age groups in 2015.
On multivariable analysis, having two or fewer positive cores, a higher socioeconomic status, being aged 56 years or older, and being diagnosed after 2012 were all associated with a significantly increased likelihood for AS/WW.
During a median follow-up period of 41 months there was no significant difference in prostate cancer mortality by age or initial management strategy, with rates below 0.3% in all cases.
Mahal et al say that these data suggest that “AS/WW may afford acceptable outcomes in younger men,” but caution that “studies with a median follow-up of at least 10 years are needed to make a better determination.”
However, the investigators believe that the “lower absolute rates of AS/WW utilization in younger patients suggests that there is more ambivalence and uncertainty toward managing younger patients than older patients with conservative management,” which they think “arises from a theoretical threat of disease progression.”
They therefore suggest: “When uncertainty arises, it may be beneficial to further evaluate with advanced magnetic resonance imaging-targeted biopsy or the addition of genomic tests that assess disease risk.”
By Laura Cowen
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