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Use of conservative management for low-risk prostate cancer ‘increasing rapidly’
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Conservative management or deferred treatment is the preferred approach for men with low-risk prostate cancer, according to results of a large VA cohort study.
Stacy Loeb, MD, assistant professor of urology and population health at NYU Langone Health and the Manhattan VA, and colleagues assessed utilization of conservative management in a cohort of 125,083 veterans newly diagnosed with prostate cancer between 2005 and 2015.
In 2005, 27% of men aged 65 years or younger chose to postpone immediate therapy and 4% elected to be managed with active surveillance. In 2015, 75% chose to forego immediate treatment and 39% chose active surveillance.
These trends persisted among men aged older than 65 years.
HemOnc Today spoke with Loeb about the distinctions between watchful waiting and active surveillance, the challenges of convincing both physicians and patients that conservative management is the preferred strategy for men with low-risk disease, and what future research should entail.
Question: C an you provide some context for the study?
Answer: There has been a lot of controversy over the years with regard to prostate cancer screening and treatment. One aspect of that is that patients with low-risk disease often have a good prognosis even without treatment. They do well even when they are just monitored over time. Guidelines recommend active surveillance as the preferred management strategy in this patient population, but it has been underutilized in many settings in the United States.
Q : Why is this approach underutilized?
A: There are many factors, both at the patient and the physician level. Patients are scared by the so-called “C” word, and they tend to think that treating upfront leads to a better outcome. We also see reluctance on the part of patients’ family members. They want the patient to get treated rather than just being observed. On the physician level, the emphasis during training of physicians — particularly among surgeons and radiation oncologists — is to do something. There is much less emphasis on nonoperative or noninterventional management options. There also is incentive for some physicians for payment for different treatment options. Overall, it’s likely a combination of these factors and not one single cause. Some patients also are not interested in the active surveillance option for legitimate reasons. For example, men who have complications from prostate biopsy may be less interested in active surveillance. Active surveillance still involves serial monitoring procedures that have potential complications. Biopsy doesn’t have the level of risk of prostate cancer treatment in terms of expected side effects. Nevertheless, it’s still an invasive procedure that may involve pain or lead to complications like infection or bleeding.
Q : How can members of the clinical community begin to overcome the barriers to uptake of watchful waiting or active surveillance ?
A : That is a very important question. The terms watchful waiting and active surveillance often are used interchangeably but they are actually very different. Watchful waiting is a conservative management approach without curative intent. Active surveillance entails continuing to do ongoing checks with the goal of starting curative treatment at the first sign of progression. Active surveillance is a continuum between less intense to more intense surveillance. It’s not black and white. One thing that may increase uptake is tailoring the surveillance regimen to the patient. An older patient with a very low-risk tumor warrants less intensive surveillance than a younger patient with a higher-volume tumor. As use of these approaches continues to increase, there will be less reluctance among patients and their families because it will be clear that this is the prevailing approach. All of this will generate more data, which will lead more physicians to adopt the approach, and all of these factors will feed together. Everyone on both sides of the equation will be more comfortable with it and strategies will evolve.
Q : Is it more important to spread this information to physicians or patients?
A: Both. We already are seeing results, as use of conservative management options has been increasing rapidly over time.
Q : Shifting gears, could you elaborate on the results of your study?
A: Our goal was to study conservative management — including watchful waiting and active surveillance — in a VA population from 2005 through 2015. The study included almost 125,000 veterans with low-grade prostate cancer. By 2015, 72% of veterans aged younger than 65 years were choosing conservative management, and 79% of those aged 65 years and older also chose conservative management. Thus, it had grown to the point that this was the primary management option.
Q : Is the uptake in a VA population greater than the uptake in non-VA populations?
A: Our paper only looked at VA data, so we didn’t study that as an outcome. However, we have seen previous publications with SEER, MUSIC, and CaPSURE data that show lower use of conservative management strategies than what we observed in the VA.
Q : Can you speculate why that might be the case?
A : It may have to do with the structure of the VA system. The VA is an integrated community, where all patients are on the same electronic record system. VA providers have regular email discussions about the best approaches and a listserv discussion of best practices. This is a very intertwined network of physicians. VA providers also do not have a financial incentive to do more treatment. It also may have to do with the veterans themselves, who may be more readily accepting of conservative management approaches.
Q : H ow do you build on this information?
A : We need to think about making surveillance protocols better to optimize these approaches. One way to think about this is individualizing intensity of follow-up for patients. We know that avoiding upfront treatment and the associated side effects can benefit many patients, but we don’t know the optimal level of monitoring and how that can differ between patients. When you look at low-risk patient groups, even within that group, there is heterogeneity. Two patients with a PSA less than 10, a Gleason score of six and a tumor with a low clinical stage can still be very different with regard to extent of cancer. One of those patients can be on the low end of the spectrum and the other can be on the high end. We need to figure out how to tailor our protocols more effectively.
Q : This seems to dovetail into the era of individualized, personalized medicine.
A: The era of personalized medicine has arrived. The future of active surveillance, as in all of medicine, is tailoring things to individual patients. I do suspect that this paradigm will continue to evolve over the next decade.
Q : What is the next step in research?
A: We have designed a mathematical model showing the impacts of active surveillance, and we are working on more studies with the model. It is a Markov model that estimates likely results using a variety of testing protocols over the course of a man’s lifetime if he has low-risk prostate cancer. The next step is to look at the model and observe how new testing options may influence the new paradigm. – by Rob Volansky
Reference:
Loeb S, et al. JAMA. 2018; doi:10.1001/jama.2018.5616.
For more information:
Stacy Loeb, MD, can be reached at NYU Langone Health, 1 Park Ave., 5th Floor,
New York, NY 10016; email: stacy.loeb@nyumc.org.
Disclosure: Loeb reports consultant fees or travel reimbursements from Astellas, Boehringer Ingelheim, Eli Lilly, General Electric, GenomeDx, MDxHealth, Minomic, Sanofi, and several other health care and pharmaceutical companies involved in cancer care or diagnostics.