Improving the application of active surveillance in community urology practices

The appropriate uptake and application of active surveillance within community urology practices is a challenge for many community oncologists and their patients for numerous reasons.

A recent paper by Gaylis et al. in Urology (the “Gold journal”) described a 3-year-long collaboration between a large community urology group in the San Diego area and the Department of Urology at the University of California San Diego. The collaboration was designed to “measure past active surveillance (AS) adoption rates, institute the best practice, and measure the AS adoption rates following implementation” within the community urology group.

In the original paper, the authors report that, over the 3 years of the initiative:

  • AS adoption rates for all newly diagnosed patients in the community practice increased from 12.9 to 14.7 percent.
  • AS adoption rates for men with low-risk prostate cancer increased from 31.9 to 58.5 percent.
  • AS adoption rates for men with very low-risk prostate cancer increased from 43.8 to 82.6 percent.

They concluded that:

These data highlight the potential benefit of physician education and comparative reporting to enhance AS adoption. AS adoption rates vary according to selection criteria used for analysis. Carefully selected outcomes from evidence-based guidelines have the potential to enhance medical quality.

However, and importantly, in a recent “Beyond the Abstract” commentary on the UroToday web site, Kane and Gaylis have provided some interesting and additional comments about this initiative that emphasize the value of this program for the community urology practice and its patients as well. We would encourage readers to register with UroToday to read the entire commentary. (There is no cost to registration.)

Here is a quote from Kane and Gaylis’s additional commentary:

The overtreatment of low risk prostate cancer is complex and there can be tremendous momentum toward treatment of newly diagnosed men both from physicians and from patients.  The momentum to treat is partially patient driven because of the term “cancer” as well as the rational fear of advanced disease and death from prostate cancer. Many patients and families are initially very resistant to the concept of active surveillance fearing that it is incomplete or undesirable management. So there is an educational hurdle that can be challenging to clear depending on patient educational level and health literacy. Many men and their families, after education about active surveillance, are greatly relieved to understand the low metastatic potential of low risk prostate cancer  and are eager to avoid the side effects of treatment. Introducing the concept of active surveillance prior to screening or prostate biopsy can be effective.  

The momentum toward treatment for physicians is multifactorial, sometimes due to fear of adverse oncologic outcomes for their patients or because of lack of knowledge or experience about active surveillance. In some situations,  business influences may  be a factor. Therefore, education is useful for both physicians and other healthcare providers. 

Optimizing the ability for physicians and patients to share an understanding of the potential value and roles of active surveillance in the management of lower-risk forms of prostate cancer –most particularly among older patients who are going to be at very low risk for prostate cancer metastasis — can be challenging. When community urology practices can work closely with others who have developed real experience in the application of active surveillance over time, there are some very real potential benefits for all concerned — the patients in particular!

3 Responses

  1. With what I am going through at my Stage IV advanced metastatic prostate cancer, the pain and suffering, I cannot imagine that I would ever have wanted “active surveillance.” Having prostate cancer is like having a ticking time bomb between one’s legs.

    The earlier a cancer is treated, the better the outcome because who knows at what point the cancer will escape and metastasize?

    How I wish that the cancer could have been cut out of me, or irradiated, or frozen or heated to destroy the cells before they got out of control. Instead, because the prostate tumor had been so very large, and had invaded the bladder and up against the rectum wall, it wasn’t possible to have surgery to cut the infernal, accursed prostate out of me, and it remains, slowly killing me, millimeter by millimeter.

    Even the removal of my testicles didn’t stop the production of testosterone, at least down to the therapeutic level.

    I’ve seen so many guys write about regretting having the prostatectomy because of ED and incontinence, and those are genuine problems, but many have lost the perspective that the removal of the prostate has saved their lives, either stopping the cancer or at least slowing the progression dramatically. I envy them.

    In hindsight, I would never have opted for active surveillance — I would have wanted to kill the cancer or have it cut out of me as quickly as possible to try to eliminate the possibility of growth and spread of the disease, and not wait — to defuse the ticking time bomb.

  2. This is welcome evidence of the growing acceptance of active surveillance.

    I am puzzled by one aspect of the report/abstract: despite a striking jump in the percentage of low- and very low-risk patients being managed with active surveillance, the overall increase — all newly diagnosed patients in the practice being managed with active surveillance — went up only slightly, from 12.9 to 14.7 percent — not even a 2% increase. This would be consistent with a practice seeing a large majority of intermediate- and high-risk men among their newly diagnosed patients, but such a large proportion of higher-risk patients seems unlikely for a community practice in the 2011 to 2014 era, which was the period of this study.

  3. Dear Eric:

    Of course you would never have considered active surveillance. You would never have been an appropriate candidate for it, and your form of prostate cancer would never have allowed you to appreciate the perspective of many men who are very good candidates for active surveillance. But you do need to understand that: (a) low-risk prostate cancer that is true Gleason 3 + 3 = 6 disease does not metastasize and (b) that form of prostate cancer is nothing at all like what you have had to deal with. Low-risk prostate cancer is by no means, necessarily, a “ticking time bomb” at all.

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