How 48 doctors think about active surveillance

Many patients, prostate cancer advocates, and prostate cancer educators may be interested in a recent article exploring how physicians who manage prostate cancer regularly think about active surveillance (AS) and how to discuss this with their patients.

The full text of this article by Pang et al. is available on line and was just published in BMC Health Services Research.

Pang and her colleagues conducted a series of five focus groups with a total of 48 Canadian physicians, all of whom regularly provide care for men diagnosed with low-risk prostate cancer. In reading this article, people based here in the US need to bear in mind that in Canada (as in the UK and Australia and many other countries) the vast majority of physicians who diagnose and treat prostate cancer are “hospital based” and employed by specific hospitals. They do not usually own their own clinical practices or work in a practice owned by another physician.

What is very clear from this article is that although the principles of AS are already widely accepted as a management option for patients with low-risk disease, the Canadian medical community is less than comfortable, as yet, with how best to implement the management of AS on a routine, day-to day basis — especially over the long term. If readers look through Table 1 of the actual article, it provides a long series of direct quotations from the participants in the focus groups through which they express their levels of confidence, their concerns, and their mindsets about how to inform and manage their patients on AS.

The greatest levels of concern revolve around the fact that, in the physicians’ opinions, we still have no really accurate, non-invasive test to tell whether a patient can safely remain on AS or needs to be advised that treatment would be wise. They are very aware of the fact that patients are uncomfortable with frequent, serial biopsies over time. However, they are also very aware that biopsies are the only mechanism they have to be able to determine, with a high level of accuracy, whether what they can see (by using various types of scanning technique) really is or is not cancer that might need to be treated.

The lack of any really accurate non-invasive test for risk of prostate cancer progression over time then plays in to the clinicians’ other major concern, which is the lack of a well-defined and standardized protocol for how to conduct AS over time. If the needed, non-invasive test existed, it would certainly make it a great deal easier to monitor patients over time and only give biopsies if and when they became absolutely necessary.

One Response

  1. “Age” of this Snapshot of Canadian Practice Re Active Surveillance for Prostate Cancer

    Thanks for reporting this. This is an interesting paper to read.

    The paper states that the focus groups took place from 2013 through 2015. That’s pretty recent. However, research is moving at a rapid clip, especially in imagery, which is relevant here especially in the area of multiparametric MRIs as an aid to decision making for potential active surveillance patients, and acceptance of active surveillance appears to be surging. Indeed, details make clear that there was what appeared to be ample awareness of rapid developments regarding active surveillance. I’m thinking this research snapshot of physicians concerns and practices in Canada indicates a lower bound to current attitudes in mid-2018, two and a half years after the latter focus groups, for active surveillance.

    One value of this paper is to get a sense for what doctors (primarily urologists in this study, but also a sprinkling of other types of doctors involved with prostate cancer), who were not, apparently, heavily involved in active surveillance research know about active surveillance. On this site we tend to see a lot of research involving experts, and this paper gives sort of a “ground-truth” image of common experience with the active surveillance option. This is an interesting paper to read.

    One impression from the paper is that it appears that patients and doctors are quite concerned about the need for and burdens of multiple follow-up biopsies with active surveillance. It is interesting that the reduced follow-up biopsy approach of the Klotz group at Sunnybrook (Toronto), which is the location of the lead author, does not seem to have penetrated Canadian practice as widely as I would have thought. Similarly, the use of multiparametric MRI, which is still coming into its own after emerging perhaps a few years before these focus groups started in 2013, was not prominent in the thinking of these doctors, though it was mentioned. In fact MRI was not available at some of the sites where the participants practiced.

    It also is evident that many of the participants were not comfortable with PSA as a monitoring biomarker. My impression is that that is a somewhat misplaced concern when there is an awareness of BPH, infection/inflammation, and lesser influences on PSA trend, but nonetheless it is a real concern for some doctors and for some of their patients.

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