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Nonsurgical Interventions to Prevent Disease Progression in Prostate Cancer Patients on Active Surveillance: A Systematic Review and Meta-analysis - Beyond the Abstract

Active surveillance (AS) is a standard of care for patients with low-risk and selected favorable intermediate-risk prostate cancer (PCa). Opting to undergo AS allows patients to maintain their health-related quality of life without compromising survival outcomes. Even though early-stage PCa is associated with favorable outcomes, the most extensive studies on AS to date show that up to 60% of patients ultimately go onto local radical treatment due to disease progression or patient desire. Although patients often inquire about the potential benefits of lifestyle changes, diet, and/or specific drugs, no interventions have been proven to delay PCa progression. We aimed to perform a systematic review and meta-analysis to assess which interventions prevent PCa progression effectively during AS.

We found that the use of 5-alpha-reductase inhibitors (5-ARI) significantly decreases the risk of disease progression by 41%. Additionally, as the REDEEM study reported, there is no difference in the risk of treatment-related adverse events (TRAEs) compared to placebo. However, these results require careful interpretations. Although all reviewed studies had a protocol for confirmatory or repeat biopsy, the criteria for initiating these biopsies varied, potentially affecting early detection of disease progression in the control group due to the PSA elevation or MRI findings. Conversely, there is a possibility that follow-up biopsies were delayed or abandoned in the 5-ARI group because of the 5-ARI-related PSA decrease. Replanned biopsies of predetermined time points would have unraveled this unknown, but this is unlikely to be attractive to patients enrolling in such a study. Biopsy protocol adherence was not clear in the studies. Therefore, the difference in the timing of biopsies between the two groups, along with the variation in the results, may have influenced the findings.

Certain anticancer drugs, such as chlormadinone, Farnesyl Transferase (FT), and enzalutamide, demonstrated effectiveness; however, these therapies are associated with significant TRAEs, limiting their use in the setting of AS. We did not observe the marked effectiveness of other interventions in preventing PCa progression. These findings underscore the necessity for personalized management strategies and ongoing research to refine the approach to care for PCa patients on AS, balancing the benefits of intervention against potential risks.

Written by: Akihiro Matsukawa,1 Shahrokh F. Shariat,2 Pawel Rajwa3

  1. Research Fellow, Department of Urology, Medical University of Vienna, Vienna, Austria; Assistant Professor, Department of Urology, Jikei University School of Medicine, Tokyo, Japan
  2. Professor and Chairman, Department of Urology, Head, Comprehensive Cancer Center, Medical University Vienna, University hospital Vienna AKH, Vienna, Austria; President of the Austrian Urological Association; President of the Central European Urological Society; Adjunct Professor of Urology and Medical Oncology, Weill Medical College of Cornell University, New York, NY, USA; Adjunct Professor of Urology, UT Southwestern, Dallas, TX, USA; Honorary Professor of Urology, Charles University, Prag, Czech Republic; Honorary Professor of Urology, University of Jordan, Amman, Jordan; Honorary Professor of Urology, University of Tabriz, Tabriz, Iran
  3. Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland.
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