Expectant management is really “coming of age” in the USA

An excellent new review article in CA: A Cancer Journal of Clinicians, along with a research letter just published in the Journal of the American Medical Association (JAMA) have provided us with an important update on the value and the increasing acceptance of expectant management in the treatment of lower-risk forms of prostate cancer.

The review article by Filson et al. does an very thorough job of explaining the potential values of expectant management and the many things we have learned about its application over the past 20 or so years. In particular, The “New” Prostate Cancer InfoLink likes the simple descriptors used by the authors to differentiate between the two primary forms of expectant management:

  • Active surveillance: expectant management with curative intent
  • Watchful waiting: expectant management with palliative intent

The full text of this article is available on line and will be a very valuable resource for all prostate cancer support group leaders and other prostate cancer educators and advocates.

At the same time, based on data from the CaPSURE registry, managed by the University of California, San Francisco, there is now what we believe to be the first clear report of a major increase in the application of expectant management as first-line treatment for low-risk disease in the USA between 2009 and 2013.

A media release issued by JAMA, together with the actual research letter by Cooperberg and Carroll, report that:

  • This analysis is based on data from
    • A total of 10,472 men with tumors classified as clinical stage T3aNoMo or lower
    • 42 community urology practices and three academic urology practices across the USA
  • Patients were initially managed by any one of
    • Radical prostatectomy
    • Radiation therapy
    • Androgen deprivation therapy (ADT), using any form of ADT monotherapy
    • Expectant management, inclusive of active surveillance and watchful waiting
  • Initial application of expectant management (inclusive of true active surveillance) for low-risk disease
    • Was low from 1990 through 2009 (varying from 7 to 14 percent)
    • Increased sharply in 2010 through 2013 (to 40 percent)
  • Initial management with ADT for intermediate- and high-risk disease
    • Increased steadily from 1990 (to 10 percent for intermediate-risk disease and to 30 percent for high-risk disease)
    • Decreased sharply after 2009 (to 4 percent for intermediate-risk disease and to 24 percent for high-risk disease)
  • Among men ≥ 75 years of age, the rate of expectant management (inclusive of true active surveillance)
    • Was 54 percent from 1990 through 1994
    • Declined to 22 percent from 2000 through 2004
    • Increased to 76 percent from 2010 through 2013
  • However, also among men ≥ 75 years of age, use of surgery as a first-line treatment
    • Increased to 9.5 percent for those with low-risk cancers
    • Increased to 15 percent for those with intermediate-risk cancers
    • Remained stable for those with high-risk cancers (among whom ADT still accounted for 67 percent of treatment).
  • Substantial variation was observed in treatment patterns across individual practices.

This report substantiates the perceived acceptance of expectant management by much of the US urology community in recent years, confirming anecdotal reports of such an increase. However, the increases seen in the application of surgery as a form of first-line treatment in men of 75 years and older do need to be viewed with some caution — particularly among those with low-risk disease.

It is possible that, as our aging society has become healthier, and life expectancy has continued to increase, there is a justification for some degree of increase in the application of first-line surgery among men ≥ 75 years of age with “unfavorable” intermediate-risk disease. It is harder to understand any justification for such an approach in men with low-risk disease, in whom the risks for significant incontinence and the consequent impact on quality of life are likely to far outweigh any real benefits in terms of overall or cancer-specific survival.

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