Active surveillance as a management strategy for younger men with low-risk disease


So a new paper just published on line  in BJU International has (finally) provided some data to support a perspective that The “New” Prostate Cancer InfoLink has believed in for a considerable period of time … that active surveillance is a perfectly reasonable option for a high proportion of patients with low-risk prostate cancer who are ≤ 55 years of age.

In this article by Kim et al., the authors use data from a large Department of Defense tumor registry and related clinical records of the servicemen involved. Their objective was to see if they could identify a population of younger men (aged < 55 years at diagnosis) with very low-risk prostate cancer (clinical stage T1c, with a PSA density of < 0.15 ng/ml/g, a Gleason score ≤ 6, and only one or two positive biopsy cores with < 50 percent tumor involvement) that were potentially good candidates for active surveillance (AS).

They looked specifically at data from patients in two time cohorts:

  • Group A: those diagnosed and initially treated between 1987 and 1991
  • Group B: those diagnosed and initially treated between 2007 and 2010

Here is what they found:

  • Compared to the men ≤ 55 years of age in Group A, men of ≤ 55 years of age in Group B were > 30 times more likely to have been diagnosed with PSA screen-detected tumors.
  • Data for a subset (n = 174) of men in Group B with PSA screen-detected cancer were evaluable for disease risk assessment.
  • 81/174 men with screen-detected disease (47 percent) had very low-risk disease, as defined above.
  • Of that group of 81 men
    • 78/81 (96 percent) selected treatment
    • 57/81 (70 percent) men elected to be treated by radical prostatectomy.
    • 49/57 men who had a radical prostatectomy actually did have tumors with favorable pathology (organ confined, < 10 percent gland involvement, Gleason ≤ 6).

Kim et al. conclude that, “Nearly half of young men with PSA screen-detected prostate cancer are AS candidates but the overwhelming majority seek treatment. Considering that many tumors show favorable pathology [after surgery], there is a possibility that these patients may benefit from AS management.”

Now this study does not provide us with definitive proof what active surveillance is the “correct” management strategy for all men under 55 with low-risk disease. On the other hand, it does provide us with a very real quantification of the size of the problem: some 47 percent of all men ≤ 55 years of age who are diagnosed today with low-risk disease (as defined above) appear to be good candidates for active surveillance.

It should also be noted that (arguably), since the definition actually used by Kim et al. is of men with very low-risk disease, the actual pool of men that requires immediate treatment as opposed to active surveillance at the time of diagnosis is considerably higher.

The point to be borne in mind here is not that early treatment for localized prostate cancer is unnecessary or ineffective in the elimination of their cancer. It is that treatment for low-risk prostate cancer in such men can almost invariably be deferred successfully until it is actually necessary, and then applied with a similar level of success. A key consequence of this decision is that younger men with good continence and good sexual function may be able to retain these for years, as opposed to suffering the potential consequences of early “over”-treatment. Apparently this finding could be reasonably applied to all men in the US who are diagnosed with prostate cancer at ≤ 55 years of age. That is hardly a small number of men on an annual basis. If it can be applied to others outside the US as well, we are starting to talk serious numbers of patients.

9 Responses

  1. I must be missing something here. Why would men with a PSA < 0.15 show up as possibly having cancer in a PSA screen?

  2. Doug:

    That is not their PSA level. It is their PSA density, which is the level of their PSA divided by the volume of their prostate in milliliters. A man with a PSA of 4 ng/ml and a prostate volume of 100 ml will have a much lower PSA density than a man with the same PSA level but a prostate volume of 45 ml!

  3. Please keep saying it; treatment should be the exception not the rule.

  4. Thanks for posting this important research about active surveillance for men aged 55 and younger.

    Since 2003 evidence has been accumulating that active surveillance is a wise option for men with low- and very low-risk cases, but many physicians have been worried about suggesting this option to young men, specifically men of 55 and younger.

    Five and a half years ago in 2007, at the first IMPaCT Conference (in Atlanta) that heralded accomplishments of the Department of Defense managed high risk/high reward research program in prostate cancer, there was a panel including representatives from some of the leading active surveillance programs in the world. The moderator was Dr. Christopher Logothetis from M. D. Anderson Cancer Center in Texas, and panel members included Dr. Stephen Freedland and Dr. Christopher Warlick (now at Duke and Wisconsin respectively but Freedland was then at Johns Hopkins, Warlick having just left), Dr. Robert Carey, Dr. Laurence Klotz of the University of Toronto, Sunnybrook, and Dr. Fritz Schroeder of Erasmus Medical Center in the Netherlands. The Toronto, Erasmus, Johns Hopkins, and M. D. Anderson active surveillance programs are all prominent and have published research. I was attending as a “consumer representative” (survivor representative) who had served on proposal selection panels.

    I asked the panel members whether there was an age limit at which they would not recommend active surveillance for younger men. Johns Hopkins was the most conservative, with Dr. Schroeder somewhat more liberal, but not comfortable with active surveillance for men younger than age 55, as I recall it. I suspect that most of us very clearly remember Dr. Klotz’s striking response: he said he believed active surveillance was appropriate for men of any age provided they had the right set of case characteristics and were monitored diligently, with younger men getting extra attention.

    This recent research is consistent with Dr. Klotz’s view. His opinion is especially significant as he directs what I believe is the largest and longest running of the major active surveillance programs.

  5. Is there data out there on what treatment options urologists themselves choose when they are found to have low- to intermediate-risk prostate cancer? I wonder if they choose to jump into RP right away as my urologist was/is wanting me to do?

  6. Ron:

    I am not aware of any good, recent data on this topic. My suspicion is that both urologists and radiation oncologists are just as “all over the map” as the rest of us. There is of course a “hard-core” group of older urologists who wear their radical prostatectomies like some sort of badge of courage and who (probably, but I can’t prove this) give their patients the “it was good enough for me, so it must be good enough for you too” speech.

  7. Halleluiah!!!

    For years my voice in the wilderness, which doesn’t carry the power of Mike’s, has called “What has age got to do with it?” in any discussion on therapy choice.

    It was always clear to me that age was not an issue — but … one of the main objections was always was that young men had more aggressive disease. There is no good study that I can find to support this — in fact the two studies I have traced contradict the general view, although noting that if a young man has an aggressive form of the disease, this might advance more fatally than in older men.

  8. Great posts. It seems we don’t have a void of rational thought for prostate cancer patients choices, but a marketing challenge.

    Why isn’t this blog on every single US urologists web site with easy access for prostate cancer patients? Why can’t urologists network collectly with active blogs instead of keeping dialogue seemingly proprietary and aloof.

    Why is it so difficult for most prostate cancer patients to understand in depth all of the patient specific choices? And, what about that pesky emotion called fear of cancer?

  9. That’s what I am doing (AS). I’m 50 years of age (49 at diagnosis), Gleason 6 (confirmed with second view of slides), T2c, 3/12 positive cores (10%, 20% and 25%), PSAs of 1.0, 1.6, 2.8 (which led to my biopsy), 1.7, 1.25, and 1.5.

    I’ve radically changed dietary intake since diagnosis, and the PSAs speak for themselves; lost tons of weight, exercising, etc.

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