Most men with low-risk prostate tumors now opt for active surveillance, but overtreatment remains a problem, according to data presented during the 2022 American Urological Association (AUA) Annual Meeting.1
A retrospective analysis of more than 20,000 patients with low-risk prostate cancer showed that approximately 60% of men who were eligible for active surveillance chose that approach in 2021, up from 27% in 2014. Authors of the study noted, however, that treatment rates among men with low-risk prostate tumors remain suboptimal, with wide variation across providers.
“Rates of active surveillance are heading in the right direction, but we are still not where we need to be, which is probably at least 80% of men with low-risk prostate cancer,” said lead study author Matthew R. Cooperberg, MD, Professor of Urology and Professor of Epidemiology and Biostatistics at the University of California Comprehensive Cancer, San Francisco. “Furthermore, the likelihood of active surveillance for low-risk disease varies drastically by urology practice and especially by individual urology provider.”
Matthew R. Cooperberg, MD
As Dr. Cooperberg explained, active surveillance is widely endorsed by major clinical groups as the preferred management strategy for all low-risk prostate cancers, regardless of volume, including new guidelines released by the AUA jointly with the American Society for Radiation Oncology (ASTRO), and for select patients with favorable intermediate-risk disease. Although the uptake of active surveillance has historically been low, rates have been rising in the past decade, said Dr. Cooperberg, who attributed the rise in part to the growing scientific literature supportive of the approach.
Dr. Cooperberg and colleagues analyzed active surveillance trends and variation in the AUA Quality (AQUA) Registry, which comprises data collected directly from urology practices nationwide. By mid-2021, AQUA included a total of 1,945 urology providers, representing 349 practices, and more than 8.5 million unique patients, including 298,081 treated for prostate cancer. Of these patients, noted Dr. Cooperberg, 27,289 were newly diagnosed with low-risk disease (prostate-specific antigen [PSA] ≤ 10 ng/mL, Gleason 6 (3 + 3), and clinical stage T1/2a); and of these patients, 20,809 (76.3%) had known primary treatment.
Primary treatments were classified as radical prostatectomy, external-beam radiation therapy, brachytherapy, androgen-deprivation monotherapy, or active surveillance. Active surveillance required the absence of any active treatment and at least one subsequent PSA value greater than 1.0 ng/mL.
Rates of Active Surveillance
As Dr. Cooperberg reported, analysis of the AQUA registry showed that active surveillance rates have more than doubled, from 26.5% in 2014 to 59.6% for the first half of 2021. Prior publications in smaller data sets have noted that fewer than 10% of men with low-risk prostate cancer chose active surveillance in 2010.
Researchers also identified “excessive variation” of active surveillance rates across providers. The proportion of low-risk patients managed with active surveillance ranged from 4% to 78% at the practice level and from 0% to 100% at the provider level, said Dr. Cooperberg.
On logistic regression, age, year, and provider were strongly associated with receipt of active surveillance, whereas race and practice were not. Regarding study limitations, however, Dr. Cooperberg noted that race data were self-reported and frequently missing. AQUA also captures radiation therapy data imperfectly, he added, and the quality of active surveillance has not yet been documented.
When asked about the goal rate of active surveillance of 80% for men with low-risk prostate cancer, Dr. Cooperberg acknowledged that the target is arbitrary, but reflects figures already achieved in Sweden, the U.S. Department of Veteran Affairs hospitals, and other contexts. “There will always be a rationale for treating selected patients, such as young men with a very strong family history and high-volume grade group 1 disease,” he explained. “These patients likely make up far less than 20% of low-risk cases, but 80% is a good number to shoot for at least for now.”
Despite the risks associated with treatment itself, Dr. Cooperberg noted that some low-risk patients may still opt for surgery or radiation therapy. The onus, however, should be on providers to educate patients about the benefits of active surveillance before the biopsy and even the PSA test, he emphasized.
“If there are patients who reasonably choose to be treated, that’s okay, but ‘patient preference’ can sometimes be an excuse to overtreat low-risk disease,” Dr. Cooperberg continued. He also emphasized that emerging biomarker and imaging tests are allowing biopsy to be used more selectively in the first place, minimizing detection of low-risk disease. “We used to think active surveillance was the antidote to overdetection, but now we’re realizing it’s best just not to diagnose these low-risk patients.”
DISCLOSURE: Dr. Cooperberg reported no conflicts of interest.
1. Cooperberg M, Meeks W, Fang R, et al: Active surveillance for low-risk prostate cancer. 2022 American Urological Association Annual Meeting. Abstract MP43-03. Presented May 15, 2022.