(UroToday.com) The 2024 South Central AUA annual meeting included a session on prostate cancer, featuring a presentation by Dr. Lisa Lowenstein discussing transitioning men to watchful waiting for prostate cancer. There is a plethora of literature regarding the safety of active surveillance and the importance of not over-treating nonlethal prostate cancer, however, less is clear regarding how and when to transition men to watchful waiting. Generally, watchful waiting (or observation) is defined as a less intense type of follow-up that includes fewer tests and that relies more on changes in a patient’s symptoms to decide if treatment is needed.
The various major oncology guidelines have different recommendations regarding watchful waiting/observation:
- AUA/ASTRO (2022): for patients with a life expectancy of less than 5 years, the follow-up plan should be no routine cancer monitoring. No explicit statements are made with regard to how to transition to watchful waiting.
- ASCO/Cancer Care Ontario (2016): for patients with a life expectancy of less than 5 years, the follow-up plan should be passive follow-up. This guidelines states that men with limited life expectancy may transition to watchful waiting and avoid further biopsy.
- NCCN (2024): for patients with a life expectancy of less than 10 years, the follow-up plan should be a history and physical exam no more than every 12 months (without surveillance biopsies). Patients should transition to observation when their life expectancy is <10 years (recommendation made via shared decision-making)
- EAU (2024): for patients with a life expectancy of less than 10 years, with a patient-specific follow-up plan (not pre-defined and dependent on symptoms of progression). Patients should transition if they remain on active surveillance as long as the patient agrees, and has a life expectancy of more than 10 years; development of comorbidities may result in a decision to transition to watchful waiting.
Dr. Lowenstein and colleagues have recently performed very important qualitative research, gathering information regarding transitioning from active surveillance to watchful waiting for prostate cancer. She highlighted several patient interactions where she notes that patients generally want to continue with active surveillance:
- A patient on active surveillance for 6 years: “…if the prostate cancer were to accelerate, how would I know before it is too late before it is stage 4 since I have no indication. If I dropped everything at the age of 72, and suddenly things were to change at age 77 or 78, I wouldn’t know until I started to develop some sort of symptoms. My thought is if I developed these symptoms, that could be an extreme form of prostate cancer. So, I could be shooting myself in the foot by not pursuing monitoring”
- A patient on active surveillance for 1 year: “I don’t understand the logic of this question. You keep going back as frequently as they want you to go back. And hopefully, as long I can possibly make it”
According to physicians, de-escalation is easier than stopping active surveillance testing:
- Physician, 25 years in practice: “We typically convert to watchful waiting when life expectancy is about 10 years. That’s just a general range when we think the man, based on his age and his health, has a life expectancy of 10 years or less; we’ll basically see them once a year for an exam and a PSA. We would no longer do routine MRIs, or routine biopsies unless something changes in terms of a new finding on digital rectal examination or if their PSAs started to increase significantly. So, most folks do not want to be terminated from the clinic so to speak. We see them once a year just to say hello, see how they’re doing, get a PSA and an exam, and that keeps them content, but also keeps them off treatment”
- Physician, 10 years in practice: “Patients don’t understand that even when you tell them that with their heart failure at 79 years of age and hospitalization, there is a likelihood they are going to die in the next few years. You’re not going to have to worry about your prostate cancer at all. They just want to keep watching because they feel like you never know”
- Physician, 26 years in practice: “I would say 80 to 90% react favorably, and there is a small group who would want persistent follow-up. And we don’t necessarily resist that right away, what we do say is ‘OK, you sure you want to come back? You don’t really need to, but if you want to we will see you back in a year or two”
Dr. Lowenstein emphasized that their group has been involved in developing shared decision making patient information, highlighting the importance of shared-decision making when discussing a transition to watchful waiting:
From a patient standpoint, Dr. Lowenstein notes that one reason to transition to watchful waiting (after a shared decision-making discussion with their clinician) is that if they have multiple comorbidities and multiple different physician follow-up appointments, not having to actively monitor their prostate cancer may be ‘one less thing to check off of the to-do list.’
Dr. Lowenstein concluded her presentation discussing transitioning men to watchful waiting for prostate cancer with the following take-home points:
- Transitioning men to watchful waiting may be challenging and will likely require multiple conversations
- Decision support interventions may improve knowledge, decrease decisional conflict, and slowly change preferences
Presented by: Lisa Lowenstein, PhD, MPH, RD, Associate Professor, Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas, MD Anderson Cancer Center, Houston, TX
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 South Central American Urological Association (AUA) Annual Meeting, Colorado Springs, CO, Wed, Oct 30 – Sat, Nov 2, 2024.
Related content: Challenges in Transitioning Men from Active Surveillance to Watchful Waiting - Lisa Lowenstein