For specific diseases, many physicians tend to recommend interventions and therapies with which they are most comfortable and familiar. It is not surprising that urologists and radiation oncologists did so in the study reported by Hoffman and colleagues in JAMA Internal Medicine and reviewed in this issue of The ASCO Post.1 It is also not surprising that “older” urologists in this study more often implemented definitive therapies compared to their younger colleagues, since active surveillance is a relatively recent approach being taught now in training programs as an option for some men with prostate cancer.
Baseline Assumptions
The National Comprehensive Cancer Network (NCCN) guidelines recommend active surveillance, radical prostatectomy, brachytherapy, and external-beam radiation therapy as options for men with low-risk prostate cancer with at least a 10-year life expectancy. These guidelines have not changed since 2009, the last year of the data analyzed in the study by Hoffman et al.
This report’s median age of 72 represents an average anticipated life expectancy of 12.72 years for 2009.2 It may be reasonable, in accordance with the principles of life expectancy estimation, to adjust this upward by 50% (6.36 years) for those in the best quartile of health.3
In addition, more than 69% of the men with low-risk prostate cancer in this study had a Charlson comorbidity score of 0, and < 10% of those diagnosed had a comorbidity score ≥ 2. Accordingly, it is reasonable to assume that the majority of men with low-risk prostate cancer in this study had life expectancy of 12.72 or more years. If the Charlson comorbidity score is relatively constant across all age groups in this report (it may not be), then the anticipated life expectancy would average about 10 years for patients aged > 80 years and marginally higher for those aged 76 to 80 years.
Reasons Underlying Recommendations
The authors postulate that the diagnosing urologist plays an important role in treatment selection. This is undoubtedly true for a variety of reasons, and the individualization of recommendations for particular active treatment options or no treatment is based on multiple factors.
As would be expected, the percentage of men who did not receive definitive therapy appropriately increased in each age cohort in the study. However, patients, physicians, and reports often inadvertently use the terms “observation,” “watchful waiting,” and “active surveillance” interchangeably, which often generates misunderstanding.
NCCN’s description of observation (watchful waiting) involves monitoring the course of the disease with the expectation to deliver palliative therapy if symptoms develop or there is a change in exam or prostate-specific antigen (PSA) findings suggesting that symptoms are imminent. This is not the same as active surveillance, an approach in which there is proactive monitoring of the stability/progression of the disease and intervention if and when the disease poses an imminent threat to the patient’s survival or quality of life.
I do offer active surveillance to appropriate patients, but I often find it to be a hard sell (I am age 67 and therefore an “older” urologist). Once disease is pathologically confirmed, many men, their spouses, and their families find the suggestion of monitoring not yet definitively established benchmarks (Gleason grade change, PSA, etc) to be counterintuitive, despite the legitimate concerns about definitive treatment in older men.
The anxiety inherent in the process also influences a relatively high number of men to initially seek out or convert to conventional treatments. An easier conversation in my experience is to dissuade “older” patients and/or those with significant comorbidities from having a biopsy even though the patients are usually referred for evaluation for prostate cancer.
In Conclusion
There is little doubt that not all men with low-grade prostate cancer have to be treated. The opening statement in the Hoffman et al report—“Low-risk prostate cancer … is unlikely to cause symptoms or affect survival if left untreated.”—is probably true, but I would add “as long as the disease remains low-risk.”
The NCCN guidelines for men with low-risk prostate cancer detail the role of expectant management. Observation (watchful waiting) is recommended for men with low-risk prostate cancer with < 10-year life expectancy. Active surveillance is an established option for men with low-risk prostate cancer and ≥ 10-year life expectancy. Active surveillance may well stand the test of time as we learn more about the natural history of this disease. ■
Disclosure: Dr. Fracchia reported no potential conflicts of interest.
References
1. Hoffman KE, Niu J, Shen Y, et al: Physician variation in management of low-risk prostate cancer: A population-based cohort study. JAMA Intern Med. July 14, 2014 (early release online).
2. Official Social Security Website: Actuarial life table. Available at www.ssa.gov/OACT/STATS/table4c6.html. Accessed July 28, 2014.
3. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer, version 2.2014, PROS-A. Available at nccn.org. Accessed July 28, 2014.
