TELL A MAN THAT HE HAS PROSTATE CANCER. Then tell him that instead of trying to treat the disease, it’s best just to watch and see what happens next.
That can be a tough sell. But oncologists say it’s often the right choice to make, and new data suggest men in the United States are increasingly doing so.
A study published online April 3 in JAMA Internal Medicine analyzed data on treatment of more than 105,000 men over 40 diagnosed with low or favorable-intermediate risk prostate cancer in the U.S. from 2010 to 2018. It found that the percentage of patients choosing to defer active treatment increased dramatically.
In 2010, about 16.4% of men over 40 diagnosed with low-risk prostate cancer elected to monitor the disease through “active surveillance” (tracking the progression of the disease with regular diagnostics) or “watchful waiting” (forgoing even diagnostic tests unless symptoms develop). By 2018 that number had increased to 59.9%. Among those with a favorable-intermediate diagnosis, numbers increased from 7.8% to 21.8% in the same period.
These findings are good news, according to lead author Bashir Al Hussein Al Awamlh, a urologic oncologist at the Vanderbilt University Medical Center in Nashville, Tennessee.
“We know data has continued to accrue (showing) this is a cancer safely monitored,” Al Hussein Al Awamlh says. “There’s truly been a tremendous push for years, more than a decade in this case, to push active surveillance.”
Al Hussein Al Awamlh says doctors have swiftly come to embrace a wait-and-see approach when it comes to these lower-risk prostate cancers, which often grow slowly or never grow at all. Earlier research found that treating such cancer diagnoses through surgery or radiation wasn’t significantly increasing survival rates, Al Hussein Al Awamlh says, suggesting that accompanying side effects—bowel issues, urinary incontinence and erectile dysfunction—were being needlessly suffered by a subset of patients.
Instead, patients at various ages could benefit from forgoing treatment, Al Hussein Al Awamlh says. If the cancer appears nonaggressive at diagnosis, elderly patients may never require treatment at all, with odds favoring another eventual cause of mortality. These older patients are often candidates for watchful waiting, using a minimalist approach that maximizes quality of life until symptoms develop.
For younger men, active surveillance means waiting to start treatment until lab tests indicate that the cancer poses a threat of spreading. This can allow patients potentially many more years of living free of side effects. Research has shown that by the 10-year mark, about half of such patients leave surveillance for active treatment, highlighting that the approach doesn’t mean choosing not to fight the cancer, but only doing so once it becomes necessary.
“Younger men are also benefiting from active surveillance,” Al Hussein Al Awamlh says. “You keep tabs on the cancer through blood tests, exams, imaging and biopsies. And you intervene prior to it spreading out.”
Better Treatment, Better Practices
Mohamad Ezzeddine Allaf, urologist-in-chief at Johns Hopkins Hospital in Baltimore, says a number of factors have likely driven the rapid adoption of the monitoring approaches for lower-risk prostate cancers. Historically, a lack of confidence in the “low-risk” label for some diagnoses led many doctors to elect treatment.
“One of the big arguments against watching or active surveillance is that somebody could be diagnosed with low risk, and a doctor and patient will ask, ‘How do we know this isn’t just the tip of the iceberg?’” Allaf said.
But Allaf says diagnostic techniques have improved in the last decade. MRI imaging, new biomarker metrics, and genomic testing have all given oncologists greater confidence that a prostate cancer is truly low risk, enabling them to recommend surveillance.
Also, research is increasingly validating the safety of surveillance. Most recently, a study published in the New England Journal of Medicine in April found no statistical difference in survival rates among those who choose monitoring or active treatment, after following a cohort of 1,600 men with lower-risk prostate cancer in the United Kingdom for 15 years.
“There’s been an explosion of literature over the last eight to 10 years,” Allaf says, “So that whenever you open a journal, it’s not uncommon to see studies validating the safety of active surveillance.”
Room for Improvement
Despite experts hailing the new study on surveillance adoption as good news, a deeper look at the data shows there’s plenty of room for improvement.
For one, Al Hussein Al Awamlh says, the 60% of U.S. patients with low-risk prostate cancer who now elect to monitor the disease still lags behind the rate of peer nations such as Sweden (74%) and Australia (67%). Both he and Allaf say a figure between 80% and 85% is probably ideal.
In addition, the data show concerning disparities among U.S. men. Patients of Hispanic and Asian descent are significantly more likely than white patients to undergo active treatment instead of monitoring. Where people live also plays a role: Those living in rural areas are less likely to choose monitoring, as are those living in the Northeast and South.
Another concern is income disparity, with patients from households making less than $60,000 a year significantly less likely to use monitoring than those making more than $75,000. While this may seem counterintuitive—those with more financial means can often better afford treatment options—both Al Hussein Al Awamlh and Allaf say this likely indicates lower-income patients have less access to quality care or doctors who follow current best practices.
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