Low-risk prostate cancer best managed with active surveillance, according to new recommendations
For most men with low-risk prostate cancer, the recommended strategy is active surveillance with regular testing to check for cancer growth rather than immediate treatment, according to guidelines from the American Society of Clinical Oncology.
In a report published Tuesday in the Journal of Clinical Oncology, ASCO endorsed recent recommendations from Cancer Care Ontario. The recommendations aim to reduce unnecessary treatment for prostate cancer and potential long-term side effects from it, according to the University of North Carolina Lineberger Comprehensive Cancer Center member who first-authored the report.
"There is an increasing awareness that active surveillance is an important approach to spare many prostate cancer patients from treatment that they don't need, and that can cause lasting quality of life effects," said the report's lead author Ronald C. Chen, MD, MPH, a UNC Lineberger member and associate professor in the UNC School of Medicine Department of Radiation Oncology. "Active surveillance should be more commonly used for patients with low-risk prostate cancer, instead of radical prostatectomy or radiation treatment."
In the new report, ASCO endorsed modified guidelines generated by Cancer Care Ontario for using active surveillance in low-risk prostate cancer. These guidelines provide practical guidance for urologists and other cancer specialists caring for prostate cancer patients by clarifying questions ranging from which patients are most appropriate for surveillance rather than treatment to when treatment should begin if a patient's cancer progresses, Chen said.
"These guidelines are trying to provide a framework for doctors and other providers on how to practice active surveillance, and to reduce variation in practice," Chen said. "Another important goal is to reduce the overuse of aggressive treatments that could cause harm to patients instead of benefit. Many patients with low-risk prostate cancer have a lower risk of dying from prostate cancer than from other causes."
The ASCO report recommends active surveillance for most patients with low-risk, localized prostate cancer, using regular monitoring with the prostate-specific antigen, or PSA, blood test, prostate biopsy and digital rectal exam. However, it does list exceptions for younger patients, African American patients, and those with high-volume cancer in the prostate – because these patients are more likely to have cancer progression with active surveillance.
"The goal of active surveillance is to monitor patients carefully so that when the cancer starts to progress, you can offer treatment such as surgery or radiation and still have a high probability to cure the cancer," Chen said.
The guideline warns against routine uses of additional tests such as MRI scans or genomic tests in active surveillance without further research.
"We don't have enough research yet to clearly show that these additional tests, which can be expensive for patients, improve patient outcomes," Chen said.
The report also clarifies who should undergo "active surveillance" versus "watching waiting." Chen said that active surveillance involves regular blood tests and biopsies, while watchful waiting involves stopping routine testing and may be appropriate for patients who are expected to live less than five years.
"For this group of patients with very limited life expectancy, we should stop surveillance, and instead, place them on what's called 'watchful waiting,' with no more PSA tests and no more biopsies," Chen said. "Because even these tests and procedures could have potential harms to patients."
Chen said studies have shown that active surveillance to be a safe approach for men with low-risk prostate cancer. A study published in the Journal of Clinical Oncology in January of 2015 led by a Sunnybrook Health Sciences Centre researcher found that the likelihood of dying of other causes for a group of men with low-risk prostate cancer in the study was about nine times higher than the risk of dying from the prostate cancer.