The value in personalization of expectant management strategies

A recent and truly excellent review in Nature Reviews: Urology offers us a very thoughtful set of insights on the role of “expectant” and “conservative” management (i.e., active surveillance and watchful waiting) in the care of men with prostate cancer today.

As we point out regularly, “watchful waiting” and “active surveillance” are by no means the same thing at all.

Watchful waiting is a passive strategy best used with older men and men with multiple comorbidities and a life expectancy of 10 years or less. It can be implemented anywhere along the diagnostic spectrum with the simple goal of avoiding unnecessary treatment of any type unless treatment is needed to manage the symptoms of progressive disease. Watchful waiting is never implemented with any intention of curing the patient of his prostate cancer. It is premised on the idea that the patient is highly likely to die of something other than his prostate cancer, even if his prostate cancer symptoms may need some form of treatment along the way.

By contrast, active surveillance is a proactive strategy designed to avoid the unnecessary side effects of curative therapy until curative therapy is shown to be necessary. A man might be on active surveillance for 9 months or 19 years before treatment was needed to attempt to eliminate his localized prostate cancer. Active surveillance (in the strictest sense) is only ever carried out on men with localized prostate cancer that is theoretically amenable to a cure.

In their recent article above-mentioned, Tosoian et al. provide a careful and thorough review of the changing ways in which expectant management is beginning to be more widely implemented around the world — not just in America, but also from Sweden to Japan and beyond. There are details in the article one might quibble with if you were a certain type of patient, but the one thing that is absolutely “unquibbable” with is the set of basic premises that appears to underlie the authors’ overall position, which we can outline by using five selected statements from the review:

[C]onservative management strategies are essential for decreasing the downstream harms of screening by  reducing over-treatment of men with low-risk disease.

Enrollment in an [active surveillance] program implies a life expectancy of > 10-15 years; however, limited data exist exploring [active surveillance] outcomes beyond 20 years. … However, whether [active surveillance] should be considered in younger men is a particularly pertinent question …

Outcomes from [programs at Johns Hopkins, Göteborg, and Sunnybrook] help illustrate the reality that the outcomes of [active surveillance] reflect a complex interaction of cancer risk, surveillance approach, and overall patient health.

The [active surveillance] literature remains limited by the lack of uniformity in reporting. Metrics such as survival free of treatment, metastasis, and [prostate cancer-specific mortality] are dependent on the follow-up duration, and should, therefore, be reported as time-specific outcomes.

A uniform approach to [active surveillance] is appealing, but current diagnostic and prognostic tools lack the precision needed to reliably monitor men with varying risks and preferences under a single optimal approach. Furthermore, the ability to discuss varying approaches to [active surveillance] and their associated risks with a newly diagnosed patient also has value.

These are merely a few statements from an 11-page-long article that discusses almost every nuance of what we now know about the appropriate use of expectant and conservative forms of management in carefully selected sets and subsets of patients. And the text is inclusive of the evolving roles of urinary markers, genomic testing, multiparametric MRIs, low vs. intermediate risk, patient age and life expectancy, and race-related risk factors.

The bottom line is that we consider this review to be essential reading for members of the prostate cancer treating and the prostate cancer education and advocacy communities today. If you haven’t read this paper, you really are probably not as well informed as you should be as to how to think about expectant and conservative forms of management today. Get yourself a copy.

And last but by no means least, Tosoian and his colleagues make one other key statement that seems extraordinarily important to us, which is that:

[Active surveillance] — like other management strategies — could be individualized based on the level of risk acceptable to patients in light of their personal preferences.

In our opinion, not only could this be done. It absolutely should. It would be one more step along the path to the improvement of care (as opposed to the implementation of treatment) for men with prostate cancer.

Editorial comment: The “New” Prostate Cancer InfoLink thanks Dr. Jeffrey Tosoian of the Brady Urological Institute at Johns Hopkins for his prompt response to our request for a full-text copy of this article (and also thanks Dr. Tosoian and his colleagues for writing the article in the first place!)



3 Responses

  1. Excellent post, thank you.

    IMO, this is the sweet spot: “[Active surveillance] — like other management strategies — could be individualized based on the level of risk acceptable to patients in light of their personal preferences.”

  2. You strongly urge everyone to read this full article. Is there any way to do so without the $32 expense apparently being charged by the Nature Review: Urology publishers?

  3. Burke: Your library (or better still a medical library) should be able to get you a free copy for personal use only.

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