Age, active surveillance, and age-related risk for progression

A new report in the Journal of Clinical Oncology suggests that younger patients had a somewhat lower risk for biopsy-based Gleason score upgrade while on active surveillance (AS) than older patients. Furthermore, patient age did not affect risk for definitive treatment in the intermediate term.

The research team (Leapman et al.) followed nearly 1,500 men who were initially managed with AS and who stayed on AS for a minimum of 6 months from study enrollment.

Here are the core study results:

  • 1,433 patients were followed for a median of 49 months.
  • 74 percent of these patients underwent their initial biopsy at a referring institution.
  • Average (median) age at diagnosis was 63 years, but,
    • 599 patients (42 percent) were ≤ 60 years old.
    • 834 patients (58 percent) were > 60 years old.
  • For the men ≤ 60 years old
    • The 3-year biopsy-based Gleason score upgrade-free rate was 73 percent.
    • The 5-year biopsy-based Gleason score upgrade-free rate was 55 percent.
  • For the men > 60 years old
    • The 3-year biopsy-based Gleason score upgrade-free rate was 64 percent.
    • The 5-year biopsy-based Gleason score upgrade-free rate was 48 percent.
  • Younger age
    • Was independently associated with lower risk of biopsy-based Gleason score upgrade
    • Persisted upon restriction to men meeting strict AS inclusion criteria.
  • There was no significant association between younger age and
    • Risk of definitive treatment or
    • Risk of biochemical recurrence after delayed radical prostatectomy.

In other words, for men on AS who turned out to need treatment after a period of time on AS, there was no suggestion that time on AS increased risk for disease progression at the time treatment was actually given.

This is an important finding because it tells us that what many men on AS fear most, i.e., that if and when they are found to need treatment that treatment will be less effective than if it is administered early, is not actually a significant risk at all.

It also shows us that it is perfectly reasonable to manage appropriate, relatively younger patients on active surveillance for a long as is reasonably possible so that they can avoid the risk for the most debilitating side effects of treatment (erectile/sexual dysfunction and urinary incontinence) until treatment really is necessary.

We would remind readers (again, as we often do) that AS is not a “treatment” for prostate cancer. It is a way of managing lower-risk forms prostate cancer in  a way that will minimize risk for the complications and side effects of invasive treatment. Some men may be able to remain on AS for many years (or even “for ever”, until they die of something else). Other men may only be able to remain on AS for shorter periods of time, but knowing that you will be able to retain high quality erectile/sexual function and avoid the other side effects of treatment for even just a year or two may be a very big deal for a very significant percentage of men — not least many of the younger ones!

6 Responses

  1. Just a note to acknowledge i read every post on this wordpress site and having a place to go that shares our mutual concerns is significant.

    Thanks for creating this place.

  2. Important information; great post. Thanks!

  3. The value of knowing that treatment was necessary

    Let’s not forget that active surveillance also functions to extend the staging process — separating the sheep from the goats. Someone with a low-risk case who jumps right to treatment and has some side effects will have to live with the knowledge that he might have had unnecessary treatment that he could have avoided. On the other hand, someone who is directed to treatment as a result of monitoring under active surveillance has the satisfaction of knowing that his treatment was necessary.

  4. Hmmm … I’m not sure it’s quite that simple Jim.

    Many community-based physicians are still (in my humble opinion) not implementing high-quality forms of AS, and are far too ready to jump from AS to treatment — particularly in older men who may progress from Gleason 6 to tiny amounts of Gleason 3 + 4 = 7 and may only have another 10 to 15 years of reasonable life expectancy (meaning that that their chances of metastatic disease or death from prostate cancer are still very low indeed).

    Also I would not agree that AS is a way to “extend the staging process”. What is important is appropriate work-up for all patients who may have low- or favorable intermediate-risk disease so that appropriate active surveillance can be offered to these patients. Just “not deciding” about whether treatment or monitoring is appropriate for a period of time is not active surveillance — although it may be an appropriate way to delay decisions for some patients.

  5. Hi Sitemaster,

    Your take from what I wrote is not what I intended. (That happens at the breakfast table too.) And I appreciate your ability to help me sharpen my thinking.

    Your point that we need well done AS and do not always see that in practice is important, of course. Based on my 17 years of having observed this disease with my life and welfare at stake, I’ve seen enough shaky practice for other patients to be confident that some AS is poorly done, though I do not recall seeing research. I’m wondering if there are any studies on that. At the moment, I can’t think of a PubMed search that would tease out that information.

    I did not at all mean that “not deciding” is a valid way to go instead of real AS. By “extending the staging process,” I’m thinking that AS, especially the first one to two years that should include a confirming biopsy and/or a multiparametric MRI, both of which can cover the status of the anterior region that is not often probed in the initial biopsy, reveals a lot more about the degree of aggressiveness of the cancer — much more than we get through the initial staging/scoring process. Soon we will probably see the emergence of some genetic testing too. Also, though controversial, I’m convinced that challenging the disease with finasteride or dutasteride is also useful in exposing the nature of the patient’s disease. (Dr. Klotz and others have written about that.) I wish I had written “expand the staging process” instead of “extend the staging process”.


  6. Jim:

    Perhaps the best way to discuss this is using a phrase like the following: “High quality active surveillance, which includes a confirmatory biopsy within the first 12 months after initial diagnosis, ideally done in association with some form of mpMRI guidance, also provides a more sophisticated form of work-up than is offered by the initial diagnostic process, and which can therefore further clarify patient risk in an appropriate manner.”

    Re the quality of active surveillance in the community setting, see here.

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