Just “delaying” surgery does increase risk … but it’s not active surveillance

A key question for men diagnosed with low-risk prostate cancer is always going to be whether, and for how long, they can defer treatment without increasing the risk that delayed treatment will be less effective (or riskier) in some ways.

A new study by Loeb et al. has helped to provide some additional insights in addressing this question, but there are very important caveats that need to be considered in evaluating the data that Loeb and her colleagues present.

Loeb et al. used data from the nationwide, population-based National Prostate Cancer Register of Sweden to identify > 7,500 men, all diagnosed with low-risk prostate cancer and Gleason 3 + 3 = 6 disease between 1997 and 2007, who went on to have a radical prostate cancer within one of three time frames:

  • Within less than a year of initial diagnosis (i.e., “immediately”)
  • Within 1 to 2 years post-diagnosis
  • After 2 or more years post-diagnosis

They then compared the available data on the outcomes of these men to see whether there were differences between the outcomes of the men who had immediate as opposed to delayed surgery.

Here are the core findings from the study;

  • The total patient cohort was 7,608 men diagnosed with low-risk prostate cancer.
  • Average (median) patient follow-up was 8.1 years.
  • Compared to men who had surgery within < 1 year after diagnosis, the men who had surgery at 2+ years after diagnosis had
    • An elevated risk for Gleason upgrading at surgery (odds ratio [OR] = 2.93)
    • An increased risk for salvage radiation therapy (hazard ratio [HR] = 1.90)
    • A similar rate of 7-year rate for prostate cancer-specific mortality

However, as Loeb and her colleagues are quick to note,

 … men with delayed RP constitute a minority with higher risk cancer among the much larger group of low-risk men initially surveilled.

It is also important to understand the abovementioned caveats about this study:

  • Most of these men in this study (and almost none of the men from a period prior to about 2005) were not being managed on what we would now be considered to be good-quality active surveillance protocols.
  • Few of the men who had deferred surgical treatment would have received a repeat prostate biopsy within 12 months of their initial diagnosis.
  • Almost none of these men would have received a multiparametric MRI or any other form of test designed to identify men who had had a Gleason 3 + 3 = 6 cancer at diagnosis but could have actually had more aggressive cancer that hadn’t been identified at initial diagnosis.
  • The follow-up time for this study is limited (as the authors also note).

So what this study is actually telling us is that, within a system that did not — at the time — really differentiate well between just “keeping an eye on” men with low-risk disease and then treating them when they seemed to need treatment as opposed to really practicing high-quality active surveillance, there was certainly a degree of risk for men being found to have higher-risk disease (and the associated consequences) when they deferred treatment for > 2 years. This is hardly a surprise.

The lesson here, for both the urology community and for prostate cancer patients, is that if we are going to practice active surveillance in the early management of low-risk forms of prostate cancer, we need to be doing this with well-structured protocols that can be customized to the needs of the specific patient or patients — based on all the data that are now available from the major centers that have spent up to 20 years learning how to do this well!

We have the tools now to do this really well. We need to be using those tools well in the best interests of patients.

3 Responses

  1. Great post! Thanks.

  2. Interesting.

    At seven years there is no difference in mortality. What is not stated is the difference in health, how many are now really ill, where surviving cancer has become a central focus in life and how many are not yet living under constant the battle.

  3. Michael:

    This is database study. That info wouldn’t have been available to the research team. The only way you could gain that type of information would be through a large, prospective, registry trial — which I happen to think would be very valuable, but everyone seems to be able to think of a reason not to do.

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