Low-Risk Prostate Cancer: Has Active Surveillance Become the New Standard of Care?

Emerging research demonstrates a 43.5 percent increase from 2010 to 2018 in the use of active surveillance (AS) for managing patients with low-risk prostate cancer in the United States.¹

For the cross-sectional study, published earlier today in JAMA Internal Medicine, researchers utilized 2010 and 2018 data from the Surveillance, Epidemiology and End Results (SEER) Prostate with Watchful Waiting (WW) database to compare the use of AS and WW for patients with low risk and favorable intermediate risk prostate adenocarcinoma.

For patients with low-risk prostate cancer, the study authors found that management with AS and WW increased from 16.4 percent in 2010 to 59.9 percent in 2018.1 The researchers also noted a 14 percent increase (from 7.8 percent in 2010 to 21.8 percent in 2018) in the use of AS and WW for patients with favorable intermediate-risk prostate cancer.1

“These data show that a diagnosis of prostate cancer no longer means a patient will undergo treatment. This further strengthens what are already compelling arguments that the benefits of screening for prostate cancer with PSA (prostate-specific antigen) far outweigh the harms. We now can, and do, avoid treating cancers that we believe will behave indolently,” noted study co-author Jonathan E. Shoag, MD, an assistant professor in the Department of Urology at the School of Medicine at Case Western Reserve University.²

(Editor's note: For related content, see "Could a New PSMA PET Agent Improve Detection of Distant Metastatic Lesions in Patients with Prostate Cancer?" and "Recurrent Prostate Cancer and Low PSA Levels: Can an Emerging PSMA PET Agent Have an Impact?")

The researchers found significant disparities for the use of AS and WW in patients with low-risk prostate cancer. Shoag and colleagues noted a 31 percent lower utilization of AS and WW use for Hispanic men in comparison to non-Hispanic White men; a 12 percent lower utilization rate for rural patients in comparison to urban patients; and a 30 percent lower utilization rate in patients with median household income lower than $60,000 in comparison to patients with greater than $75,000 in median household income.¹

The researchers also noted a 44 percent decrease in the use of AS for patients with low-risk prostate cancer who had two positive cores.¹

“Although AS series have shown an association between cancer volume on biopsy and clinical outcomes, it is unclear whether the presence of a second positive core should have such an impact on AS use,” wrote Shoag and colleagues.³ “This is worrisome, particularly with the increasing use of magnetic resonance imaging in biopsy, which may bias toward more positive cores and potentially higher rates of downgrading at prostatectomy.”

References

1. Al Awamlh BAH, Barocas DA, Zhu A, et al. Use of active surveillance vs. definitive treatment among men with low- and favorable intermediate-risk prostate cancer in the US between 2010 and 2018. JAMA Intern Med. 2023. Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2803493 . Published April 3, 2023. Accessed April 3, 2023.

2. American Association for the Advancement of Science (AAAS). More U.S. prostate cancer patients choosing active surveillance. EurekAlert! Available at: https://www.eurekalert.org/news-releases/984619 . Published April 3, 2023. Accessed April 3, 2023.

3. Schaeffer E, Srinivas S, Antonarakis ES, et al. NCCN guidelines insights: prostate cancer, version 1.2021. J Natl Compr Canc Netw. 2021;19(2):134-143.