ASCO Endorses Active Surveillance Guideline for Low-Risk Prostate Cancer

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ASCO ENDORSES and reinforces the evidence-based American Urological Association (AUA), American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO) Guideline published in 2018 in the Journal of Urology. ASCO’s endorsement of a guideline on clinically localized prostate cancer recommends active surveillance as the best available care option for patients with very low–risk prostate cancer and the preferable care option for most patients with low-risk localized prostate cancer.1

Justin E. Bekelman, MD

Justin E. Bekelman, MD

“This guideline represents the most up-to-date consensus recommendations from the major professional societies that represent the clinicians, surgeons, radiation oncologists, and medical oncologists who counsel and treat men with prostate cancer,” ASCO Expert Panel Chair Justin E. Bekelman, MD, of Perelman School of Medicine at the University of Pennsylvania, said.

Prostate cancer is the most commonly diagnosed cancer in men and the second leading cause of cancer deaths in men, according to the ASCO guideline endorsement. Because of the significant burden associated with prostate cancer, there is “great interest in maintaining the highest quality of cancer care and identifying optimal treatment that is consistent with our patients’ goals of care,” Dr. Bekelman said.

ASCO’s endorsement of the recommendations “should have an immediate impact on the important questions that patients and their clinicians want answered,” Dr. Bekelman said.

Active Surveillance

EXPERT PANEL member Stephen J. Freedland, MD, of Cedars-Sinai Medical Center, said “the key take-home message is that if you have low-risk prostate cancer, no matter what caveats you want to throw in there, we probably need to be doing active surveillance. That’s an active practice-changing stance, one that is forward looking and where we think practice should be, but it is not necessarily where practice is 100% today.”

“The ASCO Expert Panel is saying there are not sufficient data to recommend it [cryosurgery] be a part of standard treatment today.”
— Stephen J. Freedland, MD

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Dr. Bekelman said ASCO has produced a guideline endorsement on active surveillance that “provides more context and counsel for clinicians and patients, including discussion of how surveillance might be considered for men with low-volume Gleason 3+4 or grade 2 cancers.”

Communicating With Patients

DISCUSSION OF RISK—and a patient’s tolerance for risk—is an important part of a shared decision-making process with patients who have low-risk prostate cancer. For that type of discussion, using analogies to explain more common risks can be helpful, Dr. Freedland said.

“I explain that crossing a street can be a risk and driving a car has a risk, but those risks are very low, and we accept those. Nothing in life is completely risk-free, and I tell the patient that is why we need to follow him closely to make sure we don’t miss something. I explain that I think the likelihood that his cancer is going to spread and cause problems in his lifetime is very low. You need to be a bit of a salesman to get patients to hear the word ‘cancer’ and yet get comfortable not treating it,” Dr. Freedland added.

Hormone Therapy

A SECOND KEY MESSAGE in the guideline endorsement is an updated recommendation regarding the length of androgen-deprivation therapy (ADT) or hormone therapy for men with higher-risk disease. Dr. Bekelman noted that prior recommendations had considered 24 to 36 months of ADT to be appropriate. However, new evidence from the PCS IV and TROG 03.04 RADAR trials has indicated that 18 months may be equivalent and permissible.2,3 These two trials “should be followed closely,” he added.

The PCS IV trial2 compared 36 months with 18 months of ADT in patients with high-risk prostate cancer who were also treated with radiotherapy. The results found that treatment for 36 months is not superior to therapy for 18 months and that reducing ADT to 18 months did not compromise survival or quality of life.

A 10-year follow-up of the RADAR trial,3 presented during the 2018 Genitourinary Cancers Symposium, found that 18 months of ADT was more effective than 6 months in men who were undergoing radiotherapy for clinically localized prostate cancer.

Additionally, the recommendations describe high-impact quality-of-life data comparing surgery, external-beam radiation, and brachytherapy. The information updates the survivorship data presented in the original guideline, Dr. Bekelman said.

Difference of Opinion About Cryosurgery

THE ASCO EXPERT PANEL decided not to endorse the AUA, ASTRO, and SUO recommendations regarding cryosurgery. According to Dr. Freedland, the AUA Expert Panel decided there are sufficient data to support the use of cryotherapy in some situations, but the ASCO Expert Panel did not agree.

“Patients are looking for alternatives to surgery and radiation because of the very well-established side effects. This doesn’t mean that cryosurgery should never be done. The ASCO Expert Panel is saying there are not sufficient data to recommend it be a part of standard treatment today,” Dr. Freedland explained.

“We don’t know the right answer in every situation, but the patient has choices, which is a good thing. However, it can create confusion. The guideline is thorough and comprehensive for every scenario, with choices for even high-risk disease. Historically, high-risk disease meant radiation; now surgery is an equally viable option,” Dr. Freedland said. “That is why having a doctor to help guide patients through the process is more important, but more than ever it is shared decision-making. You have to be a partner, not the paternalistic doctor who says ‘this is what you should do.’”

DISCLOSURE: For full disclosures of the panel authors, visit 


1. Bekelman JE, Rumble RB, Freedland SJ: Clinically localized prostate cancer: ASCO Clinical Practice Guideline endorsement of an AUA/ASTRO/SUO Guideline Summary. J Oncol Pract 14:618-624, 2018.

2. Nabid A, Carrier N, Martin AG, et al: Duration of androgen deprivation therapy in high-risk prostate cancer: A randomized phase III trial. Eur Urol 74:432-441, 2018.

3. Joseph DJ, Lamb DS, Denham JW, et al: Ten year final results of the TROG 03.04 (RADAR) randomized phase 3 trial evaluating duration of androgen suppression zoledronate for locally advanced prostate cancer. 2018 Genitourinary Cancers Symposium. Abstract 1. Presented February 8, 2018.

Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, January 23, 2019. All rights reserved.