2. UroToday Home
  3. Recent Abstracts
  4. Urologic Oncology
  5. Prostate Cancer

Outcomes of men on active surveillance for low-risk prostate cancer at a safety-net hospital: Beyond the Abstract

Active surveillance for low-risk prostate cancer is a management strategy to mitigate risks of immediate surgery or radiation and is recently supported by AUA/ASTRO/SUO 2017 guidelines as standard of care for low-risk prostate cancer1. Active surveillance requires appropriate follow up, with PSA testing and surveillance prostate biopsies at regular intervals. Disparities in health care access, particularly for uninsured and vulnerable individuals, remain major barriers of care. 

In this study by Osterberg et al, the authors conducted a retrospective cohort study to examine outcomes of active surveillance at a safety net hospital in San Francisco, California. This population was comprised of uninsured or low-income patients in a large metropolitan area. Between 2004 and 2013, 104 men chose active surveillance. Approximately two-thirds of these patients were non-English speaking, and one quarter had a history of mental illness or homelessness. A large portion of the cohort had multiple co-morbid diseases.  Median follow up time was 29 months. During this time, 18 men (17.4%) were lost to follow up, defined as inability to find patient after three attempts at communication and no evidence of being treated in other available records in EPIC Systems CareEverywhere. Pathologic upgrade occurred in 20.6% of men, triggering treatment. Radiation was more common than radical prostatectomy (12.5 vs 7.7%). There was one cancer related death in a patient lost to follow up for 30 months, and three deaths from other causes. 

Lost to follow up rates on active surveillance are rarely reported in the literature, but range on average from 5 to 22%1-4. Future directions of AS programs in safety-net hospitals should target disease registries whereby long-term follow-up tracking of patients is centrally maintained across regional health networks.

Furthermore, addressing barriers to care among this population is critical as the field evolves to incorporate advanced imaging techniques. Multiparametric prostate MRI, molecular imaging techniques such as PSMA-PET and Axumin, MRI-fusion biopsy, and cancer genomics have enhanced the management of low risk prostate cancer and are increasingly incorporated into clinical practice. While these strategies may improve diagnostic accuracy and risk stratification, cost and availability remain primary barriers to underserved populations. Addressing social and cultural barriers, improving adherence at the patient level, and providing avenues for access is critical to ensure good outcomes within this population. 

Written by: Carissa Chu and Benjamin N. Breyer, Department of Urology, University of California San Francisco

References

1.      AUA/ASTRO/SUO Guideline 2017

2.     Newcomb, Lisa F. et al. “Outcomes of Active Surveillance for the Management of Clinically Localized Prostate Cancer in the Prospective, Multi-Institutional Canary PASS Cohort.” The Journal of urology 195.2 (2016): 313–320. PMC. Web. 3 Sept. 2017.

3.     Klotz, Laurence, et al. "Long-term follow-up of a large active surveillance cohort of patients with prostate cancer." Journal of Clinical Oncology 33.3 (2014): 272-277.

4.     Tosoian, Jeffrey J., et al. "Active surveillance program for prostate cancer: an update of the Johns Hopkins experience." Journal of Clinical Oncology 29.16 (2011): 2185-2190.

5.     Wood et al. “Active surveillance outcomes among a cohort of county hospital patients.” ASCO Meeting 2015. 

Read the Abstract