Active surveillance urged for prostate cancer - ■ Michael Woodhead - 6Minutes
The anxiety-provoking term “cancer” should be modified for patients with low grade prostate pathology who have favourable outcomes, according to new advice released this week.
A consensus statement from the National Institutes of Health (NIH) in the US notes that most of PSA screen-detected cases of cancer are now low-risk and are unlikely to cause death.
It says the natural history of prostate cancer has changed dramatically in the past three decades because of PSA screening, and about two thirds of men with prostate cancer are currently diagnosed with Gleason 6 scores.
The NIH statement says curative treatment of low-risk prostate cancer with radical prostatectomy or radiation therapy leads to side effects, such as impotence and incontinence, in a substantial number of patients.
In recent years, active surveillance has emerged as a viable option that should be offered to patients with low-risk prostate cancer, according to the statement published in the Annals of Internal Medicine.
Although no randomised clinical trials have assessed whether patients who undergo active surveillance have better or worse outcomes than those who receive immediate curative treatment, there have been reassuring results with cohort studies, the statement says.
“Early results demonstrate disease-free and survival rates that compare favourably with those reported for curative therapy.” The NIH statement emphasises that active surveillance is not the same as “watchful waiting”, and involves follow-up assessments including PSA levels, digital rectal examination, and repeat biopsy.
However, the NIH panel of clinicians express particular concern about the complications from image-guided transrectal biopsies of the prostate.
“Standardised protocols need to be developed to minimize the frequency and intervals of biopsies and to reduce associated pain and infection rates,” they suggest.
The consensus statement also notes that there are still unanswered questions about active surveillance strategies for prostate cancer, which require further research and clarification.
“These include improvements in the accuracy and consistency of pathologic diagnosis of prostate cancer, consensus on which men are the most appropriate candidates for active surveillance, the optimal protocol for active surveillance and the potential for individualizing the approach on the basis of clinical and patient factors, optimal ways to communicate the option of active surveillance to patients, methods to assist patient decision making, reasons for accepting or rejecting active surveillance as a treatment strategy, and short- and long-term outcomes of active surveillance.”
