SAN FRANCISCO, CA, USA (UroToday.com) - In a recent issue of the ASCO Post, a NIH panel of experts released a document to guide physicians in their evaluation of active surveillance (AS) of localized prostate cancer.
The concensus from the recent “State-in-Science” meeting on active surveillance reports AS a viable management option and should be offered to patients in lieu of intermediate treatment (prostatectomy or radiation therapy).
According to this NIH panel, active surveillance is a more proactive strategy than “watchful waiting.” What’s the difference? Both strategies involve monitoring the patient, but active surveillance delays curative treatment until indicated by exams, PSA and/or repeat biopsies; whereas, watchful waiting emphasizes the treating symptoms. The panel stopped short of issuing formal guidelines for active surveillance protocols explaining, “Physicians now have an NIH-vetted document that describes it as a reasonable approach,” said Patricia Ganz, MD., NIH Panel Chair and Director of the Division of Cancer Research, Jonasson Comprehensive Cancer Center, UCLA.
Q. Who is a candidate for active surveillance?
A. Men with PSA less than 10 nm/dL, Gleason score less than or equal to 6.
In the U.S. approximately 130,000 men are newly diagnosed and fall in that category but few opt for active surveillance. Instead it’s estimated 90% seek immediate treatment – radical prostatectomy or radiation therapy. These treatments have been shown to cause complications with bowel, urinary and sexual function.
Q. Why is active surveillance not widely accepted?
A. Active surveillance enables men to safely postpone treatment and the side effects but involves patience. The word, “cancer” often scares the patient and evokes an urgency to treat even when the disease is progressing very slowly and is diagnosed as low risk. Patient education and physician recommendations are necessary for the term active surveillance to become more widely understood and accepted.
Physician recommendations are very powerful. A survey referenced by the NIH panel indicates, if the patient goes to a urologist, he is more likely to recommend surgery. If the patient sees a radiation oncologist, he is more likely to be offered radiation therapy.
Q. What is the quality of life outcomes from active surveillance or watchful waiting?
A. Various medical studies suggest survival rates and disease-free rates are comparable to surgery or radiation. Results from the PIVOT trial comparing watchful waiting to radical prostatectomy in men with clinically localized prostate cancer showed no difference in prostate cancer mortality after 10 years follow-up. “If there is no difference in mortality, then quality of life is the defining issue,” said Mark Litwin, MD, MPH, Univ. of California, who presented the quality of life data to the NIH panel.
Dr. Litwin adds, "active surveillance is not without risk; repeat biopsies carry the risk of infection," referencing complications from image-guided transrectal biopsies of the prostate.
The panel recommended protocols to minimize the frequency and intervals of the biopsies and suggest more research is needed for imaging techniques, molecular classifications, and biomarkers that analyze the patient’s risk of disease progression.
ASCO Post, Jan. 25, 2012, pp 22, 25-26.
Reported for UroToday by Karen Roberts, Medical Writer
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