Active surveillance common in Ontario; less so elsewhere in Canada

Recent data suggest that active surveillance is now becoming a commonplace form of management in the province of Ontario for Canadian men with low-risk forms of prostate cancer.

Cristea et al., in an article in the Canadian Medical Association Journal, report data from patients referred to the Ottawa regional Prostate Cancer Assessment Clinic between April 1, 2008 and January 31, 2013, either because of an abnormal PSA level or because of an abnormal prostate examination (digital rectal exam).  See also this media release issued by The Ottawa Hospital.

A total of 477 of their patients had a subsequent diagnosis of prostate cancer with a Gleason score of 3 + 3 = 6.

Based on these 477 patients, the authors state that

  • 210/477 patients (44.0 percent) were initially managed on active surveillance.
  • 173/477 patients (36.3 percent) were initially treated with first-line surgery.
  • 94/477 patients (23.7 percent) received some other form of management (e.g., radiation therapy, high-intensity focused ultrasound, etc.)
  • There has been a steady annual increase in the number of low-grade patients initially managed on active surveillance
    • 11/34 men (32 percent) in 2008
    • 20/30 men (67 percent) in 2013
  • Factors associated with initial management on active surveillance included age > 70 years and an elevated Charlson comorbidity index.
  • Factors associated with initial surgery included having a palpable tumor, a PSA density > 0.2 ng/ml2, and/or more than two positive biopsy cores.
  • 62/210 men started on active surveillance (29.5 percent) received some form of treatment within a median of 1.3 years.
  • 52/62 patients who started on active surveillance went on to receive treatment because their cancer was upgraded on a monitoring biopsy.
  • 103/173 men who received immediate surgical treatment (59.5 percent) had higher-grade or advanced-stage disease on final pathologic examination.

The authors conclude that

Active surveillance has become the most common management strategy for men with low-grade prostate cancer at our regional diagnostic centre. Factors associated with immediate treatment reflected those that increase the risk of higher-grade tumours.

It is worth noting that the province of Ontario has a set of standing guidelines for the implementation of active surveillance that were initially released in 2015. A slightly modified set of the Ontario guidelines were also recently endorsed here in the USA by the American Society for Clinical Oncology (ASCO). The application of active surveillance appears to be less widely practiced in much of the rest of Canada, according to this news report from last November.

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