Much more monitoring of lower risk prostate cancer in US since 2010

According to a brief research letter in the Journal of the American Medical Association this week, there was a major increase in the application of active surveillance (AS) and watchful waiting (WW) in first-line management of prostate cancer between 2010 and 2015.

The full text of the brief article by Mahal et al. is available on line, and so interested readers can review this quickly for themselves. However, the core findings are that:

  • 164,760 men were diagnosed with prostate cancer between 2010 and 2015, and collated in the Surveillance, Epidemiology, and End Results (SEER) database.
    • 20,879 (12.7 percent) had AS or WW management as their first-line management.
    • 68,350 (41.5 percent) had radiotherapy.
    • 75 531 (45.8 percent) had radical prostatectomy.
  • In 2010
    • 31,355 men were diagnosed altogether.
    • Their average (median) age was 64 years.
    • Their average (median) PSA level at diagnosis was 6.0 ng/ml.
    • 34.2 percent of these men had low-risk forms of prostate cancer.
    • 14.5 percent of these low-risk men were initially managed on AS or WW.
    • 5.8 percent of the men with intermediate-risk disease were also initially managed on AS or WW.
  • In 2015
    • 25,140 men were diagnosed altogether.
    • Their average (median) age was 65 years.
    • Their average (median) PSA level was 6.7 ng/ml
    • 24.5 percent of these men were diagnosed with low-risk prostate cancer.
    • 42.1 percent of these low-risk men were initially managed on AS or WW.
    • 9.6 percent of the men with intermediate-risk disease were also initially managed on AS or WW.

In other words, there was a nearly threefold increase in the percentage of low-low men initially being managed on AS or WW. This is clearly a good thing since it reduces the risk of men being subjected to overly early and unnecessary over-treatment.

However, …

What this new paper does not tell us is

  • Whether all these men were being managed well on AS and WW, and
  • Whether there were similar or different increases in the percentages of men being managed on AS as opposed to the men being managed on WW.

AS and WW are not in any way interchangeable terms for “monitoring” men with low-risk prostate cancer. Indeed, it is arguable that if WW has been being used correctly for most of the past 30 years, then there should have been little change in the percentage of patients being managed on WW from 2010 to 2015, and that all of the change should be due to increased use of AS.

6 Responses

  1. Before commenting, Sitemaster, please note the average age in 2010 per what I received was 64, not 54.

    There are a couple of interesting issues with this study. It was sent to me pre-release by a journalist asking for comment.

    There was indeed an increase in the amount of AS/WW. However, there was also a decline in the number of low-risk diagnoses and an increase in the number of high-risk diagnoses. And while we cannot see this from the published chart, the letter sent to JAMA states:

    “Radical prostatectomy use declined among men with low-risk disease but increased among patients with higher-risk disease.”

    This was the journalist’s thrust … Why is this and what do we as advocates observe?

    I suggest this reflects:

    (1) The 2011 USPSTF recommendation that discouraged PSA testing. As a result we see less early stage disease diagnosed, and more high-risk (later stage) disease.

    (2) Many men will see a urologist first, and that can bias the surgery decision

    (3) There has been greater acceptance of AS for men with intermediate (3 + 4) disease; that (a) increases AS overall, and (b) may reflect in higher surgery in more advanced cases as a percentage of those men become eligible for active intervention.

  2. Tx for the related link @Wolfram Blattner.

    I pick up on this quote from the Prostate Cancer Foundation (PCF):

    “This encouraging finding suggests that clinicians are better adhering to current recommendations and guidelines for men with low-risk prostate cancer, as the use of active surveillance in appropriately selected men will reduce rates of overtreatment,”

    PCF sees what it wants to see … more AS! It does not see or at least comment on fewer low-risk diagnoses. I comment on this because this is the second time I have seen a questionable interpretation of data by PCF in a week. At their Blue Jacket Fashion Gala, PCF claimed that prostate cancer deaths have flat-lined and diagnoses declined. That is not what the annual American Cancer Society statistics indicate.

  3. Dear Rick:

    I would merely observe that the American Cancer Society’s projections of cancer diagnoses and deaths are notoriously unreliable. Their projections over time have rarely correlated with the actual, later data on diagnoses and deaths.

  4. Tx Mike …. what source would you recommend for the most reliable numbers on diagnoses and deaths?

  5. Rick:

    There is no utterly reliable US database because everything is based on mathematical modeling. However, the only one I place any high level of trust in is the actual (as opposed to the projected) SEER database. The latest actual actual data from SEER is from 2015 (see here). These data state that in 2015:

    — The overall prostate cancer mortality rate was 18.93 per 100,000 (down 38.9% since 1975)
    — The overall incidence of new cases of prostate cancer was 105.00 per 100,000 (up 11.7% since 1975)

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