Urologists’ advice factors heavily in choosing active surveillance for prostate cancer
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Key takeaways:
- Urologists more often recommend active surveillance over treatment for low-risk prostate cancer.
- Patients’ perception of having more serious disease factored into active surveillance decision.
Men with low-risk prostate cancer chose active surveillance more often than surgery or radiation when urologists recommended that course of action, according to study results published in Cancer.
However, urologists recommend active surveillance less often to Black men due to the higher incidence and mortality from prostate cancer among that patient population.
“Some of them may worry Black patients, on average, have more progressive cancer they may miss, that didn't show in the initial biopsy,” Jinping Xu, MD, MS, FAAFP, professor at Wayne State University, told Healio. “Keep in mind that these results reflect patients’ recall or their perception of urologists’ treatment recommendations. We didn’t ask their urologists directly in the study.”
Background and methodology
Healio reported previously the American Cancer Society projected prostate cancer to have the second most diagnoses in 2024 (299,010), but its study projected the mortality rate as below 12%.
The mortality rate for low-risk prostate cancer is even lower, according to Xu.
The high incidence and low mortality of prostate cancer make active surveillance a viable and preferred option for low-risk disease because most of these cancers do not cause problems if left untreated. Meanwhile, the adverse events associated with surgery and radiation can be life-changing.
“The treatment can cause a serious complication like impotence, incontinence and rectal bleeding — all those nasty problems you don't want to have,” Xu said.
Clinicians have supported active surveillance more over the last several years because of that, she explained.
“Ten years ago, we did a similar study, but with a smaller sample size,” Xu said. “Only 10% of people chose active surveillance. Then we did this study, and we were surprised more than 50% of men chose active surveillance. This is welcome news but not yet reached the level it needs to be.”
The Treatment Options for Prostate Cancer Study (TOPCS) examined the rates of active surveillance use and evaluated the factors associated with selecting this management strategy over surgery or radiation.
Study investigators also aimed to determine whether Black men and white men are choosing active surveillance similarly.
Researchers identified men in the Detroit area and Georgia under 75 years of age diagnosed with low-risk prostate cancer from January 2014 to June 2017. They chose those two locations because of their large Black populations.
Men received study materials in the mail, which included demographic questions as well as those about active surveillance, their knowledge of prostate cancer and how they arrived at their treatment decision.
Results and next steps
The study included 1,688 men, of whom 57% chose active surveillance (61% of white patients, 51% of Black patients).
Nearly 85% of men who chose active surveillance said their urologist recommended that course of therapy, but a lower proportion of Black men reported their urologists recommended active surveillance than white men (38% vs. 49%).
Men also had a higher likelihood of choosing active surveillance if they and their physician made the decision collaboratively, and more white men felt that way than Black men (39% vs. 32%). Another factor for choosing active surveillance included knowledge of prostate cancer.
“The shared decision making means the physicians share their knowledge about the pros and cons of different treatment options, the patient shares their preferences and then they decide together,” Xu said.
Conversely, men who identified as making the treatment decision themselves chose radiation or surgery significantly more. Roughly 75% of these patients believed they would live longer than 5 years if they chose treatment rather than active surveillance, and about 33% of patients who chose treatment perceived their condition as “serious” or “very serious,” although everyone included in the study had low-risk prostate cancer.
“Correcting these misperceptions of cancer seriousness and the unrealistic expectation that they would live longer with treatment is very important because they are not supported by evidence,” Xu said.
“The recommendation from this is to ask urologists to make a shared [decision with] their patients,” she added. “And to educate patients that they don’t need to rush to treatment because your cancer is low risk. We can watch. We can monitor. If there’s a sign of cancer progression, then we’ll treat.”
Men in the Detroit area chose active surveillance more frequently over those from Georgia as well, and Xu believes that is — at least partially — because of the efforts of the Michigan Urological Surgery Improvement Collaborative.
“They looked at individual urologists and what percentage of their patients with low-risk prostate cancer are on active surveillance. Then they provided this feedback to urologists,” Xu said. “With this individual feedback, they can see what their performance relative to their peers is in terms of evidence-based quality care indicators. I believe the individual feedback and education help accelerate [uptake of] active surveillance among the urologists in Michigan.”
“Active surveillance has been found safe and effective for the majority of patients with low-risk prostate cancer regardless of race, and it is still underutilized in the U.S,” Xu added. “In this study, we have identified some of the facilitators and barriers to active surveillance adoption so targeted patient and urologist education can further improve the quality of patient care for low-risk prostate cancer.”
For more information:
Jinping Xu, MD, MS, FAAFP, can be reached at jxu@med.wayne.edu.
Perspective
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Samuel Haywood, MD
Active surveillance for prostate cancer is an important option, minimizing the potential burden and morbidity from treatment while safely monitoring the malignancy for any notable changes. Although we as a community have made great strides in encouraging patients to consider active surveillance for low-risk prostate cancer, important research still continues to understand why some patients elect active surveillance and some elect for upfront definitive therapy.Xu and colleagues provide excellent further insight. In the TOPCS study, the investigators found that the single strongest determinant of active surveillance uptake was physician recommendation. This is not surprising. Patients often ask me, “What would you do?” This emphasizes the critically important job we have to counsel and assist patients in their treatment decisions.
When faced with a cancer diagnosis, few patients will independently ask about an option to simply monitor the cancer. However, if provided with the relevant information and counseled appropriately regarding the safety of this approach, many patients elect for the active surveillance approach. Indeed, other factors beyond physician recommendation noted in this study associated with active surveillance included prostate cancer knowledge and shared decision-making. Recognizing and understanding the low-risk nature of this disease allows patients to feel comfortable with the surveillance approach.
Of note, in this study, more white men were recommended active surveillance by their providers, and this correlated to a significantly higher percentage of white men than Black men electing for active surveillance. Further research is necessary to understand physician recommendations for or against active surveillance for Black men, and additionally to understand the factors that determine active surveillance utilization in this population. Are providers uncomfortable with this option given the higher rates of aggressive prostate cancer in Black men? It is important to study this further to make sure we are equitably providing excellent cancer care.
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