William Catalona, MD, Professor of Urology at Northwestern University’s Feinberg School of Medicine, and past Principal Investigator on the Northwestern-based prostate SPORE, explained the evolution of his views regarding active surveillance in men with low-risk prostate cancer. Although conservative management of prostate cancer has existed for decades, he said, active surveillance was introduced in the 1990s and gradually rose to prominence with the introduction of prostate-specific antigen (PSA) testing, which significantly increased detection of low-grade and low-volume cancers.

“It was a revolutionary idea that someone could be diagnosed with cancer and simply be watched and not treated, especially with prostate cancer, which was a major cause of death from cancer,” Dr. Catalona told The ASCO Post. “I initially thought patients were rolling the dice by not having their cancer treated as early as they could because prostate cancer death rates were so high.” Over time, however, numerous studies have demonstrated the benefit of active surveillance. Dr. Catalona and colleagues at the Prostate Cancer Active Surveillance Project have recently set a goal of 80% uptake of active surveillance in patients with low-risk disease.

William Catalona, MD

Dr. Catalona, who is also researching biomarkers to distinguish patients who may be harboring more life-threatening disease, has identified genetic factors that could predict poor performance on active surveillance. Approximately 40% to 50% of patients with low-risk prostate cancer come off active surveillance within 5 years because of rising PSA levels or the detection of higher-grade cancer via biopsy.

“Improved biomarkers could help us quantify the extent that certain patients are rolling the dice on active surveillance,” said Dr. Catalona. “Genetic factors associated with aggressive prostate cancer are still in the early stages of development, however.”

Despite patients being categorized as low risk, Dr. Catalona also cautioned against underdiagnosis of low-grade prostate cancer. Recent analysis of the Surveillance, Epidemiology, and End Results database showed that of the 21,896 deaths from prostate cancer that occurred between 1992 and 2017, 55.6% occurred in men initially diagnosed with low-grade disease.¹ “The majority of prostate cancer deaths in the United States still occur in men initially diagnosed with low-grade disease,” he said. “If these men aren’t initially diagnosed, then they won’t be adequately surveilled.” 

DISCLOSURE: Dr. Catalona reported no conflicts of interest.

REFERENCE

1. Clark R, Narod S: Patterns of mortality after prostate cancer. 2021 Society of Urologic Oncology Annual Meeting. Abstract 224. Presented December 3, 2021.