Active surveillance among African-American males — some confusion

The appropriateness and utility of active surveillance as a management strategy for African-American men diagnosed with low-risk forms of prostate cancer appears to be becoming an issue of some mild controversy.

A review article just published in Urology (by Silberstein et al.) apparently suggests that

Active surveillance for low-risk prostate cancer (PCa) in African-American men is a safe and reasonable option, despite evidence suggesting they are more likely than Caucasian men to have worse pathologic and oncologic outcomes.

However, we have not seen the full text of the article by Silberstein et al., and the above quote comes from an editorial comment in Renal & Urology News, in which the original article was discussed.

Other articles published earlier this year (by Odom et al. and by Jalloh et al.), by contrast, have indicated that African American men managed on active surveillance are at significantly higher risk for disease progression than comparable Caucasian patients, and that, consequentially, such patients need to be followed a great deal more closely and with a high regard for risk of progression than their Caucasian comparators.

It is worth nothing that Silberstein et al., working at Tulane University in New Orleans, are clearly following all their active surveillance patients with a high degree of attention to detail. Apparently their management protocol includes the application of multiparametric MRIs within 6 months of initial diagnosis followed by directed biopsies; repeat physical examinations and PSA measurements every 6 months; and repeated imaging and biopsy at 24 months. In the conclusion of their report they are said to write that

Our use of aggressive imaging, biopsy, and follow-up regimens is likely to mitigate any increased risk, which remains unclear in [active surveillance].

The bottom line here seems to be that we are still in the process of ironing out just how “active” active surveillance needs to be for well-defined groups of patients. It is clear that, on the one hand, excessive and unnecessary annual biopsies are not necessary for a large number of men on active surveillance. On the other hand, it is becoming apparent that men who have a higher level of risk within the low-risk criteria for eligibility for active surveillance may need to be followed more closely than others. African-American patients would seem to be one subset of those higher-risk patients, and so if they are to be monitored on an active surveillance protocol, that protocol does need to be relatively aggressive in its design to catch any risk for progressive disease early.

It should also be pointed out that the amount of data accumulated to date on the use of active surveillance among African Americans is limited.

What is clear is that active surveillance still needs to be applied with care and caution in all men as a tool to manage low-risk forms of prostate cancer. This is even more true when we consider its application in the management of men who have other racial, genetic, and familial risk factors (e.g., African Americans) just as it is when we are considering the role of active surveillance in older men with small amounts of intermediate-risk prostate cancer (e.g., one or two cores of Gleason 3 + 4 disease but a PSA < 10 ng/ml and clinical stage T1c). We are still learning how to use active surveillance really well, and we still need more and better data to inform and support the decision-making process.

As we continue to accumulate the necessary data, the clear message to men in the African-American and Afro-Caribbean communities is this. If you discuss active surveillance with your physicians after a diagnosis of low-risk prostate cancer, make sure you are also discussing the precise management protocol that will be necessary. Something close to the protocol being used at Tulane University may be wiser than just PSA tests every few months to see if your PSA is stable.

8 Responses

  1. Where’s the controversy? I don’t get it …

  2. Walt:

    The controversy is around whether African Americans should even be offered active surveillance for low-risk disease. It’s not a major issue yet, but …

  3. Not a wise idea. No one ever points out that a biopsy is only a representative sample that only evaluates part of the prostate. You could have high-grade cancer sitting next to lower grade and miss it. African-American men should not be part of active surveillance as the risk is too great and no one can say when or if some cancer cells have escaped into the bloodstream during that period of time. I am a prime example. (Gleason 6 on biopsy upgraded to 4 + 3 = 7.) MRI and DRE were negative. If I had waited for surgery, things could have been worse in a short period of time. We need the truth, not fiction. By the way I am a practicing physician. Dont wait, your life could depend on it!

  4. Dear Dr. Keith:

    So the truth is that, much as we might like to, we don’t live in a perfect world with perfect tests that can be used to make perfect decisions about all sorts of things medical.

    Your decision worked for you. Others might (and actually do) have different perceptions — including both physicians and non-physicians of my acquaintance. As you correctly point out, every patient should be made aware that a biopsy does not provide data about absolute truths, but patients also need to know all sorts of other things that they don’t always get told — starting with the fact that there is no known treatment for prostate cancer that doesn’t come with significant risks for complications and side effects. None of us is capable of simply making the decision for another person about what they “should” or “shouldn’t” want to do. Only they can do that. What they need is the best possible information on which to base that decision.

    Active surveillance may well be a very bad idea for some African Americans (e.g., one of 56 with a Gleason score of 6 whose uncle died of prostate cancer). That doesn’t mean that it may not be a perfectly reasonable one for another (one of 70 with a Gleason 6 and with no history of prostate cancer in his family at all).

    Life decisions are rarely black/white decisions. They come in all sorts of shades.

  5. (Psst, Keith, if you are indeed a “practicing physician” you should know that AS decisions are based upon all the numbers: PSA history, Gleason score, clinical stage, tumor volume, and others.)

  6. I believe I have addressed reasonably comprehensively what any patient considering Active Surveillance should consider before embarking on this option in this article, and, as I learn of reliable information to add, I will certainly do so.

  7. Of course there are a lot of.factors that go into deciding how one would address their diagnosis. My point is that many times patients are not given all of the information they need to make the best decision. It is a fact that this disease is diagnosed frequently later and can progress more rapidly in the AA population. As a consequence if a population of people are at greatest risk for a particular disease then the general recommendations on screening and management may not be applicable. They may require a stepped up approach to their management. Without a doubt there are socio-economic factors that come into play when monitoring a disease, so it is important to look at the big picture and in the community where I practice access to regular medical care is an important variable.

  8. Dear Dr. Keith:

    And absolutely no one would have any argument with the importance of that set of statements.

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