Can Active Surveillance Be Expanded for Prostate Cancer Patients?

September 21, 2017

Can Active Surveillance Be Expanded for Prostate Cancer Patients?

  1. Allan S. Brett, MD

Both low- and intermediate-risk patients did well, but follow-up averaged only 4 years.

  1. Allan S. Brett, MD

Active surveillance (AS) — an alternative to immediate prostatectomy or radiotherapy — is used increasingly for patients with low-risk, prostate-specific antigen (PSA)−detected prostate cancer. In this report from Cleveland Clinic, researchers present their experience with 635 patients who received AS; 82% had low-risk disease (Gleason 6 with other low-risk features), and nearly all of the remaining 18% had intermediate-risk disease (mostly Gleason 7 with other higher-risk features). AS was not standardized, but adjunctive testing (e.g., magnetic resonance imaging, genomic testing of biopsy specimens) was used in some cases, in addition to serial PSA testing and periodic biopsy.

Median follow-up was 4 years; one quarter of participants had longer than 7 years of follow-up. One third of participants eventually underwent prostatectomy or radiotherapy. During continuing follow-up, no patient has died from prostate cancer, and only six patients (1%) have developed distant metastases; the low-risk and intermediate-risk groups have done equally well.

Comment

Although this is a single-center case series — without a strict AS protocol and without uniformly long-term follow-up — it suggests that AS could be expanded selectively to include patients with intermediate-risk PSA-detected cancers. Growing use of AS instead of immediate prostatectomy or radiotherapy is one reason the U.S. Preventive Services Task Force recently has become more receptive to PSA screening (NEJM JW Gen Med May 15 2017). However, persistent skeptics might argue that a growing population of patients undergoing AS still creates burdens (medical, psychological, and economic) that offset the relatively small absolute benefit of PSA screening.

Editor Disclosures at Time of Publication

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

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