Recent utilization of active surveillance to defer treatment in Sweden

Although many US urologists and radiation oncologists consider that active surveillance is a highly appropriate form of management for low and very low-risk forms of prostate cancer, the actual use of active surveillance in clinical practice here in the USA is still limited … so it is interesting to see recent data from Sweden on this topic.

Loeb et al., in a paper just published on line in the Journal of Urology, used the nationwide Swedish prostate cancer registry (Prostate Cancer database Sweden or PCBaSe) to look at data on the use of both active surveillance and watchful waiting among newly diagnosed Swedish men. The various risk groups were defined as follows in this study:

  • Very low risk: clinical stage T1c; Gleason score ≤ 3 + 3 = 6; PSA < 10 ng/ml; PSA density < 0.20 ng/ml/cm3; with ≤ 2 positive biopsy cores or <25 percent of cores positive for cancer
  • Low risk: clinical stage T1 or T2; Gleason score ≤ 3 + 3 = 6; and PSA < 10 ng/ml
  • Intermediate risk: clinical stage T1 or T2; Gleason score 7; and/or a PSA 10 to 20 ng/ml

Loeb et al. were able to identify a total of 57,713 men who fell into the very low, low, or intermediate risk groups within the PCBaSe in the period from 1998 to 2011. Beginning in 2007, it was also possible to discriminate between men who had very low-risk as opposed to “just” low-risk disease, and to differentiate between men being managed on active surveillance as opposed to simpler watchful waiting forms of monitoring.

With that set of introductory comments, here is what Loeb et al. report:

  • A total of 21,967/57,713 men in the PCBaSe database (38.1 percent) had chosen some form of deferred treatment since 1998.
    • 13,272 had very low- or low-risk disease.
    • 8,695 had intermediate-risk disease.
  • Since 2007 it was possible to tell that
    • 59 percent of newly diagnosed men with very low-risk disease had elected active surveillance.
    • 41 percent of newly diagnosed men with low-risk disease had elected active surveillance.
    • 16 percent of newly diagnosed men with intermediate-risk disease had elected active surveillance.
  • Age at diagnosis was easily the strongest determinant for the election of deferred treatment of any type.
  • Education, marital status, and co-morbidities were significantly but weakly associated with the decision to defer treatment.

The authors conclude that, since 2007, deferred treatment for low- and intermediate-risk forms of prostate cancer has become commonplace in Sweden and that “Dissociating diagnosis from treatment in men with a low risk of progression can decrease the rate of over-treatment.”

Clearly there are sociocultural issues (among healthcare professionals and among patients) that make acceptance of deferred treatment easier and more likely for Swedish men (and perhaps for men in other European nations too) than it seems to be to date for U.S.-based patients. Some in America are likely to argue that “socialized medicine” is designed to encourage older men not to seek treatment for low-risk forms of prostate cancer because of the cost factor. Of course some in Europe (and even some in America) might argue that unrealistic expectations on the part of patients and commercial interests on the part of physicians may be what makes it more difficult for Americans to look realistically at the benefits of deferring treatment and avoiding the risks of over-treatment.

5 Responses

  1. Could the reason for such a higher acceptance of conservative management in Sweden compared to the U.S. be because patients are getting more balanced counseling about the pros and cons of the different therapies and the very small benefit of aggressive treatment in those groups?

  2. I believe Gerald has it right. The mentality I’ve have found in the USA is, get it out as fast as you can! Without really considering the patient, and without really analyzing what he feels is best for him.

    Besides cost, I feel they are taking a bit more time to be doctors and relate better to their patients.

    As patients, we depend on our doctors. However, unfortunately, now we have to depend on ourselves more and more. But, not being trained, the more we read, the more we could get confused, sadly. That’s why I find this forum is so important and helpful.

  3. Kudos!

  4. I agree with Ruben and Gerald.

  5. My Us Too chapter may not be typical, but for several years now a low- or very low-risk, newly diagnosed patient would be encouraged to consider active surveillance (AS) as a wise therapy choice. He would most likely pick up a pamphlet that enabled him to see how his “type” of case compared with intermediate- and high-risk types, with AS recommended for low-risk prostate cancer that met six criteria (as set forth by the active surveillance conference in 2007). He would also have access to DVDs with at least four video presentations on AS by leading experts (Carter, Babaian, Carroll, and Klotz), as well as by others. We have free copies of Invasion of the Prostate Snatchers available, a book which encourages thoughtful consideration of risk and presents AS favorably.

    Considering the timeline, we were much less encouraging of AS back in 2007.

    We are seeing a marked increase in interest in AS, but we also have men coming to the meeting who want the prostate out and in a jar as fast as possible.

    I’m interested in what other support and education chapters are doing regarding AS.

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