• Posted April 4, 2023

Most Men With Low-Risk Prostate Cancers Now Forgo Immediate Surgery

Over the last decade, more and more Americans with early-stage prostate cancer have put off radiation and surgery, the standard treatment options, new research indicates.

Instead, many U.S. men with low- or intermediate-risk prostate cancer have embraced "active surveillance,"in which their disease is carefully monitored for any sign of progression that might eventually require intervention.

In the new study, the investigators found that since 2010 the number of low-risk prostate cancer patients who have chosen active surveillance over immediate treatment has shot up from 16% to roughly 60%.

In the same timeframe, surveillance has also risen among intermediate-risk patients, jumping from about 8% to 22%.

The trend appears to reflect the fact that "professional societies have advocated for active surveillance of low-risk cancers for over a decade now,"said study lead author Dr. Bashir Al Hussein Al Awamlh, a urologic oncology fellow at Vanderbilt University Medical Center in Nashville, Tenn.

"The theory behind active surveillance is that some cancers have a low potential to spread outside of the prostate and are non-lethal,"Al Hussein Al Awamlh noted. In such cases, immediate treatment is not necessary.

Studies indicate that over 10 years, about half of all low- and intermediate-risk patients who choose surveillance over treatment will eventually need to undergo treatment, he said.

But "active surveillance allows us to watch these cancers closely, using blood tests, imaging modalities and biopsies to ensure they do not progress,"Al Hussein Al Awamlh added.

The main goal: to "avoid subjecting patients to the side effects of upfront radiation or surgery that affect urinary and sexual function,"he explained.

And that's not a minor concern, said Dr. Yaw Nyame, an assistant professor in the department of urology at the University of Washington School of Medicine, in Seattle.

Nyame, who was not involved in the investigation, said he "always likes to remind folks that all of our treatments that are confined to the prostate have the potential to impact a patient's quality of life, by impacting urinary function, bowel function and sexual function."

And some of those side effects can be "life-altering,"he noted, given that prostate surgery entails a 15% risk for incontinence and a 50% risk for erectile dysfunction in the five years post-treatment.

Radiation also entails a similar sexual function risk, Nyame added, alongside a "pretty high rate"for so-called urination frequency, diarrhea and bowel disturbances over the six to 12 months following treatment.

"So, for me, the risk of dying from prostate cancer needs to be big enough without treatment that it makes all of these treatment side effects worthwhile,"Nyame said.

That's where active surveillances comes in, said Al Hussein Al Awamlh. By definition, when a cancer is deemed to be low-risk it means that the chances that the cancer will ultimately spread remains low. And "we believe we can catch these cancers before they progress," he said.

So how do doctors know when a patient has low- or intermediate-risk prostate cancer, versus aggressive late-stage cases requiring immediate intervention?

Al Hussein Al Awamlh said a determination is made on the basis of factors such as tumor size; biopsy results; blood tests designed to measure levels of prostate-specific antigen (PSA); and whether or not the cancer in question "has broken through the outside layer of the prostate."

Nyame said, since the early 2000s, several studies have shown that for those diagnosed with low- or medium-risk disease, "the active surveillance strategy is safe."Among those who choose surveillance, only about 3% end up with advanced stage 4 cancer over 10 years, he noted, and less than 1% die from their illness.

For that reason, both Al Hussein Al Awamlh and Nyame pointed out that public health guidelines -- like those outlined by the National Comprehensive Cancer Network -- strongly advise doctors to advocate for active surveillance over immediate treatment when appropriate.

The current study suggests the message has been catching on.

The investigators analyzed information from a U.S. database including men over 40 who had been diagnosed with low or "favorable"intermediate-risk prostate cancer between 2010 and 2018. During that time, active surveillance numbers jumped to 60% and 22%, respectively, according to the report.

The good news came with some caveats, however. The study authors noted that American patients are still much less likely to choose surveillance than their European peers.

In addition, active surveillance was less often presented as an option and/or chosen by Hispanic men, rural residents and men of lower means, the study revealed. That, said Nyame, suggests "we're not equitable in how we approach this."

The findings were published online April 3 in JAMA Internal Medicine.

More information

There's more on active surveillance of prostate cancer at the American Cancer Society.

SOURCES: Bashir Al Hussein Al Awamlh, MD, urologic oncology fellow, department of urology, Vanderbilt University Medical Center, Nashville, Tenn.; Yaw A. Nyame, MD, MS, MBA, assistant professor, University of Washington School of Medicine, Seattle, and physician, Fred Hutch Cancer Center; JAMA Internal Medicine, April 3, 2023, online