Family history of prostate cancer should not determine active surveillance eligibility

Family history did not appear associated with increased risk for aggressive disease among certain men with early prostate cancer, according to study results published in BJU International.

Although the results suggest family history may not be a significant factor for determining active surveillance eligibility for most men with prostate cancer, further study is needed to determine the impact of race on this decision.

James M. Dupree

Active surveillance has become common for men with low-grade prostate cancer; however, eligibility criteria varies and it has not been established whether family history should be considered.

James M. Dupree, MD, MPH, assistant professor in the department of urology at University of Michigan, and colleagues from the Michigan Urological Surgery Improvement Collaborative (MUSIC), reviewed 536 previously published studies that evaluated family history of men with prostate cancer eligible for active surveillance.

The final analysis included six studies. Overall, family history did not appear associated with increased risk for prostate cancer progression. However, one subgroup analysis showed family history increased risk for prostate cancer progression among black men.

HemOnc Today spoke with Dupree about the study results, their potential clinical implications and what future research must address.

Question: What prompted this study?

Answer: The statewide quality improvement MUSIC initiative, formed 5 years ago, includes an initiative designed to create a roadmap for improving the appropriate use of active surveillance. Two surgeons within MUSIC — Brian Lane, MD, urologist in the department of surgery at Michigan State University, and Michael L. Cher, MD, chair of urology at Wayne State University — have led this effort for the past 2 years.

One question that arose was: Should a patient with a family history of prostate cancer be excluded from active surveillance? Physicians have different opinions. We reviewed all research publications on this topic to help us inform the appropriateness criteria for use in MUSIC.

Q: How did you conduct the study?

A: We searched peer-reviewed publications that evaluated the presence or absence of family history of prostate cancer, as well as how it affects disease aggressiveness and surveillance outcomes. We screened more than 500 papers and included six publications in the analysis. The publications structured their analyses differently, but they helped answer the question of whether having a family history of prostate cancer places the patient at greater risk for aggressive disease or progression and, therefore, whether they should be eligible for active surveillance.

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Q: What did you find?

A: We did not find strong evidence that family history of prostate cancer increased a man’s risk for disease progression. However, one study showed black men with a family history of prostate cancer may be at increased risk for disease progression. A limited number of studies have evaluated black men with family history of prostate cancer, so we are unable to make a strong conclusion. It is important that this group is studied more deeply.

Q: Why might black men be at increased risk for disease progression?

A: Literature suggests black men are more likely to be diagnosed with aggressive disease. Potential explanations include genetics and health care access. This is an area of active study by many research groups.

Q: Did the findings surprise you?

A: I hypothesized that family history might matter. I was a little surprised family history did not appear associated with worse outcomes on active surveillance, with the exception of the one subgroup analysis of black men. I also was surprised at the consistency of these studies. They included different designs, studied slightly different endpoints and included different populations. A clear message emerged, and that does not always happen when you review published literature on a topic. We reviewed previously performed research in an organized and systematic way. However, our study has limitations and is not definitive. Larger studies — and studies that include black men with a family history — are needed to ensure the findings are as accurate as possible.

Q: Will you conduct additional research on this topic?

A: The MUSIC collaborative is implementing a quality improvement program to optimize the use of active surveillance for men with prostate cancer. This will include monitoring how men do when they are managed with active surveillance.

Q: Is there anything else that you would like to mention?

A: This study is part of MUSIC’s quality improvement efforts, and although there are five researchers listed on the publication, it takes a much broader team to do this work. The MUSIC coalition includes more than 250 urologists from Michigan. This publication reflects the work of this statewide group of urologists who are devoted to ensuring that men in our state get the best possible prostate cancer care. – by Jennifer Southall

Reference:

Dupree JM, et al. BJU Int. 2017;doi:10.1111/bju.13862.

For more information:

James M. Dupree, MD, can be reached at University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109; email: jmdupree@med.umich.edu.

Disclosure: Dupree reports grant funding from Blue Cross Blue Shield of Michigan. MUSIC receives support from Blue Cross Blue Shield of Michigan’s Value Partnerships program.