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Men choosing active prostate cancer surveillance show low rates of follow-up monitoring
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CHICAGO — Most men who choose active surveillance of prostate cancer fail to undergo guideline-recommended monitoring by year 2 after diagnosis, according to study data presented at ASCO Annual Meeting.
The study also found that nearly one in five patients (19%) who chose active surveillance converted to active treatment for their prostate cancer despite only half of them experiencing disease progression.
“Many published studies, including clinical trials from academic institutions, have shown that with close monitoring, active surveillance is safe and patients do not miss the opportunity for cure,” Sabrina Peterson, BS, medical student at The University of North Carolina at Chapel Hill, and Ronald C. Chen, MD, MPH, associate director of education at UNC Lineberger Comprehensive Cancer Center, told HemOnc Today in a joint statement. “As active surveillance becomes more and more used across the country, we wanted to study if patients are indeed receiving regular monitoring.
“The goal of this study is not to reduce the number of patients choosing active surveillance, rather, the results of this study should increase awareness and efforts to ensure that active-surveillance patients are monitored with appropriate frequency,” Peterson and Chen explained.
The researchers conducted a prospective observational study of 346 men in North Carolina with newly diagnosed low- or intermediate-risk prostate cancer who chose active surveillance of their disease instead of treatment between 2011 and 2013.
The investigators used patient-reported outcomes data to evaluate the decision to move from active surveillance to treatment, including MAX-PC — a validated measurement of prostate cancer anxiety — and Clark’s prostate cancer decision regret. The group also evaluated guideline-adherent monitoring during active surveillance using National Comprehensive Cancer Network guidelines, which call for PSA testing every 3 to 6 months and prostate biopsy within 18 months of the initial diagnosis.
The analysis found that 15% of patients who chose active monitoring adhered to guideline-recommend follow-up testing by the 18-month mark after diagnosis. The adherence rate fell to 13% at 2 years after diagnosis.
Sixty-seven percent of patients had PSA testing in the first 6 months after diagnosis, which decreased to 27% at 2 years. Only 43% of patients underwent prostate biopsy by the 2-year mark. The follow-up rate with a urologist was 97% in year 1 but decreased to 67% by year 2.
“We were surprised at the low percentage of patients who received guideline-recommended monitoring within the first 2 years of diagnosis,” Peterson and Chen told HemOnc Today. “We had expected higher adherence rates to start, and a possible decline in adherence over time, but our study shows that even at the start, adherence is low.”
Nineteen percent of patients converted to treatment by year 2 after diagnosis; nearly half of the patients who converted to treatment did so despite having no disease progression.
The multivariable analysis showed that MAX-PC score (OR = 1.8; P = .008) and younger age were significantly associated with conversion to treatment. Overall, 94% of patients said they expressed no regret in choosing active surveillance at 2 years after diagnosis.
“Patients and clinicians need to be careful when taking results from clinical trials — which are done in controlled and highly rigorous settings — and applying them to everyday clinical practice. Although active surveillance has been shown in clinical trials to be safe — in a setting when patients are rigorously monitored — it may not be as safe when patients do not receive the necessary monitoring tests,” Peterson and Chen said.
“Given our study findings, it is important for clinicians who perform active surveillance to create a system that better ensures patients receive the necessary monitoring. If some patients are not willing or able to follow through with rigorous monitoring tests, then treatment instead of active surveillance may be a better option.”
Guideline-driven assessment in active surveillance of prostate cancer can help ensure treatment adherence, as well as guide decisions about whether to switch to active treatment, according to Stewart Fleishman, MD, of the nonprofit Coachella Valley Volunteers in Medicine, who provided commentary on the study findings at ASCO Annual Meeting.
“As Peterson and colleagues show, it decreases the amount of anxiety that these men have and that of their families, because it’s usually a family decision about whether to switch from active surveillance to some type of surgery, radiation therapy or sometimes even hormone treatment.” – by Drew Amorosi
Reference:
Peterson S, et al. Abstract 6512. Presented at: ASCO Annual Meeting; May 31-June 4, 2019; Chicago.
Disclosures: Peterson reports no relevant financial disclosures. Chen reports consultant/advisory roles with Accuray, Bayer, Blue Earth Diagnostics and Medivation/Astellas; and research funding from Accuray. Fleishman reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Fleishman reports no relevant financial disclosures.
Perspective
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Eric A. Klein, MD
Successful active surveillance depends on two factors — choosing patients with the right biology and a favorable psyche.
According to SEER data, active surveillance is now the most frequently used management strategy for newly diagnosed men with low risk prostate cancer in the United States.
Based on large cohort studies from Baltimore and Toronto and randomized data from the United Kingdom, there is evidence-based consensus on the safety of this approach and who is eligible for surveillance. Lacking, however, is evidence for what the follow-up regimen should be, including when and how to perform repeat biopsies and validated indications that should trigger definitive treatment. Also lacking is knowledge about the risks of missing recommended follow-up evaluations and well-defined adherence strategies.
This study, which showed that only one-third of men in a community cohort adhered to recommended follow-up, highlights the need to answer both of these questions. For men to gain advantage from deferring or avoiding treatment, all risks must be defined, including long-term risks for tumor progression, risks associated with repeated biopsies, and psychological well-being. This report should stimulate efforts to address all of these questions.
Reference:
Mahal BA, et al. JAMA. 2019;doi:10.1001/jama.2018.19941.
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