The appropriate implementation of active surveillance as a management strategy

In addition to the prior article on management of low-risk prostate cancer in Canada comes another article that highlights the importance of what is called “active surveillance” (as opposed to what may actually be much less sophisticated forms of monitoring).

Loeb et al., in an article in the Journal of Urology, looked at whether “active surveillance” (as conducted in community practices in the USA from 2001 to 2009) met the standards being set for true active surveillance as it was being defined during the same time period in major academic settings (e.g., at places like the University of Toronto, Johns Hopkins, and the University of California, San Francisco). Even during the period 2001 to 2009, true active surveillance protocols were based on regular and frequent PSA tests, rectal exams, and follow-up biopsy protocols. We have more recently added the potential for regular multiparametric MRI tests to that list.

By using data from the SEER-Medicare database, Loeb and her colleagues were able to identify a cohort of > 5,000  prostate cancer patients who did not receive any form of curative treatment within 12 months of diagnosis but did receive one or more additional prostate biopsies after their initial diagnosis. This would suggest that these patients were being classified as “active surveillance” patients because one does not normally re-biopsy a man who is on watchful waiting.

Here are the study data reported by Loeb et al. based on this patient cohort:

  • All patients were 66 years of age or older.
  • The total patient cohort comprised 5,192 men who had been diagnosed with prostate cancer.
  • Of these 5,192 men
    • > 80 percent had received ≥ 1 PSA test per year
    • < 13 percent had received a repeat biopsy after the first 2 years of follow-up.
    • MRI studies were rarely implemented during the study period.
    • Recent diagnosis and higher income were associated with a higher frequency of surveillance biopsy.
    • Older age and greater co-morbidity were associated with fewer biopsies.
    • African-American men underwent fewer PSAs but similar numbers of biopsies compared to white men.
  • In a subset of > 1,300 men diagnosed between 2004 and 2009, and followed on active surveillance for up to 5 years,
    • 11.1 percent met the testing standards of the University of Toronto/Sunnybrook group.
    • 5.0 percent met the testing standards of the Johns Hopkins group.

Loeb and her colleagues conclude that, during the period from 2001 to 2009,

In the community, very few elderly men receive[d] the intensity of AS testing recommended by major prospective [active surveillance] programs.

These results do hold a lesson — for patients, for community urologists, and for the urology profession as a whole. That lesson can be summarized as follows:

  • Active surveillance and classical patient monitoring (“watchful waiting”) are not the same things at all. They should be carried out for quite different and highly defined reasons in specific patient types,  … and with very different intent.
  • Patients (as well as urologists) need to understand and appreciate the distinctions between active surveillance and watchful waiting protocols.
  • Collaborative educational partnerships between community urology practices and academic medical centers can be (and have been) set up and implemented to assure the appropriate application of active surveillance within community practices.

There is also an increasing need for guidelines for the urology community about standard practices for the appropriate selection and monitoring of patients on either active surveillance or watchful waiting protocols, and guidelines as to when treatment with curative intent should be discussed and/or recommended for men who start out on active surveillance.

One Response

  1. Kudos to the researchers — a neat approach!

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