Active surveillance in management of younger men with prostate cancer

Your sitemaster has long argued that it is perfectly reasonable for many younger men diagnosed with low- and very low-risk forms of prostate cancer to be managed initially on active surveillance (despite reticence on the parts of many physicians and many patients).

A newly published paper by Maran et al. in the journal Urology has now provided additional justification for your sitemaster’s belief (see also this commentary on the Cancer Therapy Advisor web site).

Maran et al. carried out a meta-analysis of data from eight studies that included 6,544 men managed initially on active surveillance. The median age of all 6,544 patients was 65.8 years. However, …

Maran et al. were also able to show that:

  • Patients had a 13 to 17 percent lower risk of Gleason score upgrading per decade of decreasing age (odds ratio [OR] = 0.83, P = 0.004 and hazard ratio [HR], 0.87, P < 0.0001).
  • Patients also had a 12 to 20 percent lower risk of pathological biopsy progression (OR per decade decrease in age = 0.80, P < 0.0001 and HR = 0.88, P = 0.04).

Thus, just as an example, compared to a 70-year-old patient, a 50-year-old patient with prostate cancer who was on active surveillance had a 24 to 40 percent lower risk of biopsy progression, and a 26 to 34 percent lower risk of Gleason score upgrading.

Maran et al. concluded that

… in order to avoid interventional-related adverse events and to enhance quality of life, AS may be considered for younger patients. Further randomized control trials are warranted to compare the safety of AS versus other definitive treatments in young patients who are eligible for AS.

Now, it is clearly important for younger men to have a serious discussion with their doctors about the risks and benefits of active surveillance as compared to early invasive treatment if they are diagnosed with low-risk or very low-risk prostate cancer. And it becomes even more important to have that serious discussion if younger men are diagnosed with “favorable” intermediate-risk prostate cancer. There is no “right” or “wrong” answer about what to do in either of these circumstances because so much is going to be dependent on three very specific intangible issues:

  • The patient’s fear of death from prostate cancer
  • The patient’s fear of loss of sexual ability (and other side effects of early treatment)
  • The patient’s willingness and ability to take “risk/benefit”-based decisions

All that your sitemaster can offer as guidance today is that if he personally was still 55 years of age (which he isn’t) and he was diagnosed with very low-risk, low-risk, or a relatively small amount of favorable intermediate-risk prostate cancer tomorrow, his initial choice of management would almost certainly be active surveillance (if for no other reason than that it would give him time to decide what he really wanted to do — if anything).

Since your sitemaster is actually 70 years of age, he is absolutely certain that if he personally was diagnosed with very low-risk, low-risk, or a relatively small amount of favorable intermediate-risk prostate cancer tomorrow, his initial choice of management would definitely be active surveillance, and it might well still be active surveillance if he was diagnosed with a small amount of unfavorable intermediate-risk prostate cancer.

But these are very personal choices, and other men can and should feel able to come to other decisions without any sense that they are being “judged” by their peers on the rightness or wrongness of those decisions.

2 Responses

  1. Agree 100%. Dx at 49, still on it at 55. Six years under the belt on AS. Those 6 years of normal life are not immeasurable in earthly quantities.

    I blew off that whole “but you’re young so you should …”, in about 30 seconds.

    “No,” I said, “actually, I’m young so I am way too young to be out of the game!”


  2. A Problem With Randomized Trials of Active Surveillance Versus Immediate Treatment in Younger Men

    Your review made excellent sense to me, Sitemaster, but I have an issue with the authors’ (Maran et al.’s) conclusion that randomized trials are needed to compare the safety of AS versus definitive treatment in such younger men.

    One problem is that other forms of medical evidence have so well established the soundness and safety of AS for younger men that it would be virtually unethical to provide informed consent materials that neutralized that record, and such neutralization would probably be needed to foster adequate trial enrollment. Another problem is that the field of AS for prostate cancer and of prostate cancer technology generally is advancing so rapidly that there would be great practical problems with such a trial, which would seemingly have to require quite lengthy follow-up, such as a decade or even much longer. This is the issue that “SUM” mentioned in a recent post.

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