Active surveillance or immediate surgery for low-risk prostate cancer: let’s look at the math

A new study has attempted to calculate the impact of age, health status, and patient preference on the relative outcomes (and merits) of immediate surgery as compared to active surveillance for the management of low-risk prostate cancer.

Liu et al. used highly structured mathematical modeling techniques the calculate the quality-adjusted life expectancies, the actual life expectancies, the prostate cancer-specific mortality rates, and the years of treatment side effects for 200,000 men diagnosed with low-risk prostate cancer and treated with either active surveillance or immediate radical prostatectomy.

They used model parameters derived from the available literature to simulate outcomes for men aged between 50 and 75 years with poor, average, or excellent health status.

The core results of this study suggest the following:

  • For 65-year-old men with low-risk disease in average health, compared to active surveillance, immediate radical surgery resulted in
    • 0.3 additional years of life expectancy
    • 1.6 additional years of impotence or incontinence
    • A 4.9 percent decrease in prostate cancer-specific mortality
    • A net difference of 0.05 fewer quality-adjusted life years.
  • Increased age and poorer baseline health status favored active surveillance.
  • With greater than 95% probability, active surveillance resulted in net benefits compared to immediate radical surgery
    • For men older than 74 years in excellent health
    • For men older than 67 years in average health
    • For men older than 54 years in poor health.
  • Patient preferences toward life under surveillance, biochemical recurrence of disease, treatment side effects, and future discount rate affected optimal management choice.

The authors conclude (based on this purely mathematical model) that, “Older men and men in poor health are likely to have better quality adjusted life expectancy with active surveillance.” However, they go on (helpfully in our opinion) to emphasize the obvious, which is that “specific individual preferences impact optimal choices and should be a primary consideration in shared decision making.”

4 Responses

  1. It is still all about patient centered care. The patient must be given complete information from someone in the healthcare system, preferably his provider. Then how to proceed with treatment must be a shared decision. From reading posts from men with prostate cancer on this site and other sites, this just isn’t happening. We all need to work to empower men to take control of their healthcare and ensure that the healthcare system responds in a positive manner to that empowerment.

  2. It’s important to define “low risk” in terms of Gleason score (2-6), when asking if active surveillance produces results equal to or better than immediate prostate cancer surgery. What defines “low risk” in the research you’ve cited?

  3. Dear Rabbi Ed:

    In the full text of the article, the authors explicitly characterize “low risk” according to the D’Amico criteria: clinical stage T1c–T2a, PSA less than 10 ng/ml and biopsy Gleason score less than 7.

  4. More statistics, but missing the key one — doubling time. You can have “low risk”, below Gleason 6, but a fast doubling time in months. My Gleason was 5, but if I had waited a year for my next PSA it would have been above 200 because my doubling time was 3 months! If you are on active surveillance you must determine your doubling time and get frequent PSA tests.

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