Other interesting active surveillance data from the AUA meeting in Orlando

In addition to the Sunnybrook data already reported today, three significant other studies presented at the AUA meeting have provided us with valuable information on the practical application of active surveillance.

Loeb et al. (see abstract no. MP62-06) looked at data from a series of 634 Swedish men who had a delayed radical prostatectomy after active surveillance and compared these data to a matched set of 634 men who had had immediate radical prostatectomy. They found that

  • The 634 men identified from the National Prostate Cancer Register of Sweden who underwent a radical prostatectomy after a period of active surveillance were more likely to have higher grade disease at the time of surgery.
  • On multivariable analysis controlling for other factors, delayed radical prostatectomy was associated with a greater risk of an increased Gleason score (> 7) at time of surgery.
  • Despite these differences, there were no significant differences in biochemical recurrence, secondary treatment, or prostate cancer death between the two groups at a median follow-up of 7 years.

In a media release issued by the AUA, Dr. Loeb is quoted as follows:

Not all prostate cancers require immediate radical treatment, which makes active surveillance a very viable option for some men. These data suggest active surveillance with selective delayed therapy, such as radical prostatectomy, is a viable strategy for reducing the risk of overtreatment and is an important consideration for physicians to discuss with their patients.

Jeldres et al. (see abstract no. MP58-20) reported on a study in which they set out to determine whether,  in men with low-risk prostate cancer, active surveillance would result in better health-related quality of life outcomes than more aggressive therapies such as immediate surgery. As one part of this study, they looked at data from 278 men at eight institutions who were enrolled in the Center for Prostate Disease Research national database between January 2007 and December 2011. Baseline data on health related-quality of life, as well as follow-up data at 1- and 2-year intervals, were collected from men who selected either active surveillance (n = 103) or radical prostatectomy (n = 175). The results from this study show that:

  • At 2 years after diagnosis of prostate cancer, sexual function declined for both groups, but much larger declines were seen in the radical prostatectomy group (–25.4) than in the active surveillance group (–7.5), and this difference was statistically significant (p < 0.001).
  • Also at 2 years post-diagnosis, urinary function declined for both groups, but much larger declines were evident in the radical prostatectomy group (–14.0) than in the active surveillance group (–4.6); this difference was again statistically significant (p < 0.001).
  • Finally, there were no statistically significant differences observed with respect to bowel function, physical health, or mental health between the two groups.

It would be interesting to know similar and long-term data from the Sunnybrook cohort of patients, but it is not clear whether the relevant data have been collected in ways that low them to be compared to similar men who elected to have immediate treatment.

What is very clear, on the other hand, is that the ability of physician groups to keep in close contact with patients who are on active surveillance is a key part of the patient experience and patient compliance.

Hefermehl et al. (see abstract no. MP45-02) report on their experience, over a period of 13 years, in monitoring a series of 157 men on active surveillance, starting in 1999, at Cantonal Hospital in Baden, Switzerland. They report that:

  • 30/157 patients (19 percent) refused to attend for a confirmatory biopsy.
  • 44/157 patients (28 percent) required definitive treatment.
  • “Almost all” of these 44 men were “cured” of their cancer (i.e. they showed no sign of biochemical progression post-treatment).
  • Loss to follow-up is considerable, with 27 percent of all patients not returning for recommended appointments.
  • 50 percent of patients remained in the active surveillance group.
  • 11 percent of patients were lost to follow up.
  • The overall drop-out rate for the study was 36 percent.

How much of this may be attributable to communication issues? We don’t know the answer to that question? As noted earlier in commenting on the data from the Sunnybrook cohort, it requires significant effort to maintain a close and effective relationship with men who are on active surveillance. This necessitates a “mindshift” for urologists from the surgical mindset to the long-term care mindset. Not all urologists will be well equipped to make this mindshift, and the relationship between practice coordinators and nursing staff and the patients to ensure that the patients do attend for their regular monitoring visits is probably essential. Another factor would be the frequency of biopsies. Few men are likely to be willing to undergo annual re-biopsies as part of a long-term active surveillance protocol — especially now that Klotz and his colleagues seem to have demonstrated that this is not, in fact, a necessary element of sound clinical care (as opposed to its value in research studies).

The subtitle of the abstract of this paper by Hefermehl et al. is “Malcompliance is a major concern in the long-term”. While that is one way to look at the situation, another way to look at this would be that long-term compliance requires care and thought and effort on behalf of physicians and their practices. The actual results reported by Hefermehl et al. are not, in fact, that different from those reported by Klotz et al. for the men who actually stayed on active surveillance (although the frequency of biopsies in the Swiss series is not given in the abstract).

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