A new Vanderbilt University study published in the Journal of the American Medical Association finds patients with low-risk cancers can maintain their quality of life with active surveillance (2017; doi:10.1001/jama.2017.1704).
According to recent data from the American Cancer Society and NCI, prostate cancer is currently the third most common cancer in the U.S., and the most common of all experienced by men.
While American Cancer Society data does show prostate cancer is the third-leading cause of cancer death in men, and that about one in 39 men will die from the disease, the statistics regarding those with diagnoses who do not face mortality as a result are intriguing. Indeed, one in seven men will be diagnosed with prostate cancer during his lifetime. And according to the most recent data, including all stages of prostate cancer, the 5-,10-, and 15-year survival rates are (nearly) 100 percent, 98 percent, and 95 percent, respectively.
The Active Surveillance Answer
Although there are many patients for whom surgery or radiation treatments may be the best course for addressing their cancer, more physicians are presenting their patients with active surveillance options that do not have the same negative side effects for their quality of life.
The study, led by Vanderbilt University Medical Center's Daniel Barocas, MD, MPH, “ ... compared the side effects and outcomes of contemporary treatments for localized prostate cancer with active surveillance in order to guide men with prostate cancer in choosing the best treatment for them.”
“Patients who were treated with surgery or radiation had side effects, while those who were managed with active surveillance, for the most part, did quite well,” Barocas said. “It is best to avoid treatment if you have a prostate cancer that is safe to observe. This is why most doctors recommend ‘active surveillance’ for low-risk cancers,” he said.
However, Barocas did caution that prostate cancer tends to be slow growing and patients would need to be followed for 10 years or more to find differences in mortality.
“This study shows that, despite technological advances in the treatment of prostate cancer, both surgery and radiation still have a negative effect on quality of life,” said co-author David Penson, MD, MPH, Chair, Department of Urologic Surgery, Vanderbilt-Ingram Cancer Center. “Certainly, if a man has low-risk prostate cancer, he should seriously be considering active surveillance as a reasonable way to go.”
Shedding light on some other side effects of surgery and radiation, Barocas said, “Urinary incontinence was reported as a moderate or big problem in 14 percent of men 3 years after surgery compared to 5 percent of men who had radiation. Men who had radiation reported more problems with bowel function and hormone side effects compared to men who had surgery, but these differences were only seen within the first year following treatment.”
Inside the Study
Seeking to take a closer look into this study, Oncology Times spoke with Penson about some key components of the team's research, as well as how the active surveillance process works for patients with prostate cancer.
Given the findings, one area of interest was in ascertaining what defined patients and their cancers as “low-risk,” as well as what symptoms or lack thereof were present in those cases. “In our study, about 40 percent of patients were considered low-risk, which means they had PSAs below 10; non-aggressive looking cancer on the biopsy according to the pathologist; and basically normal, or close to normal, digital rectal exams,” Penson said. “When we look nationally, the proportion of newly diagnosed, localized prostate cancers that are low-risk is also around 40 percent. Most of these patients have no symptoms whatsoever. If they do, they may have some mild voiding symptoms, although these are often due to benign enlargement as opposed to the cancer.”
Delving deeper into the relatively common occurrence of prostate cancer, Penson was asked to speak to how often those patients under active surveillance ultimately require greater intervention such as radiation or surgery.
“Looking at other studies with longer term follow-up, anywhere from a third to a half of patients end up undergoing an aggressive intervention,” he said. “It's important to remember, however, that many of these studies were initiated early in the active surveillance era, so patients were more likely to get nervous and request aggressive intervention for ‘peace of mind’ than we see today. Because active surveillance is more mainstream now, I think in more modern cohorts we will see about 20-30 percent of men ultimately requiring an aggressive intervention with long-term follow-up.”
When discussing if there were other factors, such as age, which would influence his recommendation of active surveillance for certain patients with prostate cancer, Penson reiterated that the low-risk nature of the cancer in numerous cases is what leads him to direct patients toward that course of care. And that it is not advisable, regardless of age, for aggressive more aggressive forms.
“Active surveillance is a reasonable option for most men with low-risk disease, in my opinion,” Penson said. “It doesn't have to be restricted to older men. Personally, if I had low-risk, localized prostate cancer, I would start with active surveillance and I am in my early 50s. That's not to say that surgery or radiation is inappropriate in low-risk patients. Many men still opt for aggressive interventions for a variety of reasons, but active surveillance is certainly something that should be considered. That being said, active surveillance is not an appropriate option for men with intermediate or high-risk disease. Studies show that these tumors are faster growing and that aggressive interventions prolong survival and minimize complications from cancer.”
Furthermore, an article in the urologic journal BJU International by the University of Michigan's Jim Dupree, MD, stated that even a family history of prostate cancer should not be a disqualifying factor when considering active surveillance (2017; doi:10.1111/bju.13862).
“Our results suggest that having a family history of prostate cancer should not automatically exclude men from being considered for active surveillance treatments, although some questions remain about risks for African-American men with a family history of prostate cancer,” said Dupree, senior author of the review. “Men obviously need to have thorough conversations with their doctors about risks, benefits, and options, and more research needs to be done to confirm these findings, especially among African-American men.”
A Positive Prognosis
Finally, speaking to the encouraging long-term survival statistics for patients with prostate cancer, Penson stressed that, in cases of low-risk cancer under active surveillance, the prognosis is quite good.
“In men with low-risk disease, it's highly unlikely they will die of prostate cancer regardless of their treatment choice, which is why active surveillance makes sense,” he concluded. “Since most of these men are asymptomatic to start with, their quality of life is as though they didn't have cancer. When patients go on active surveillance, the cancer doesn't go away, but rather it lies dormant in the majority of patients and causes no problems. ... The bottom line is that in low-risk disease, the prognosis is excellent and as such, the prognosis with active surveillance is excellent as well.”
Tamer Abouras is a contributing writer.