Active Surveillance Underused
SAN DIEGO—Almost half of all patients diagnosed with prostate cancer could be treated using active surveillance (AS) based on National Comprehensive Cancer Network (NCCN) guidelines, but fewer than 10% actually receive this treatment strategy, data from a recent study suggest.
The investigation, which was conducted by researchers from Tufts Medical Center and Tufts University in Boston, used information from the Surveillance Epidemiology and End Results (SEER) database on 37,646 men diagnosed with non-metastatic PCa in 2006 who had sufficient information on their T-stage, PSA, and Gleason score. Based on NCCN guidelines, the researchers determined the proportion of men for whom AS could be recommended as either the sole treatment strategy or one of the treatment options, and they compared this number with the actual number of men who were treated with AS.
A total of 12,183 patients were categorized as having low-risk disease. AS should have been the only treatment for 2,941 of them, yet only 712 (24%) were actually managed with this strategy. Twenty-five percent received external beam radiation therapy (EBRT), 20% received brachytherapy, 3% received EBRT plus brachytherapy, and 18% underwent radical prostatectomy (RP).
AS was an accepted treatment option (among other choices) for 9,242 low-risk patients, according to the investigators. Of these, 1,624 (18%) received AS, while 17% were treated with EBRT, 21% were treated with brachytherapy, 3% were treated with EBRT and brachytherapy, and 35% were treated with RP. In the intermediate-risk group, AS was an accepted option for 5,084 patients, of which 1,281 (25%) received the treatment. Others in the group received EBRT (29%), brachytherapy (9%), EBRT plus brachytherapy (6%), or RP (24%). The NCCN guidelines do not recommend AS for high-risk patients or those with locally advanced disease.
When looking at the total study sample of 37,646 men, the researchers found that 46% could have been managed with AS according to NCCN guidelines, and 9.6% actually received it. Extrapolating these percentages across the total number of patients with prostate cancer annually in the U.S. (192,000), the researchers determined that 88,000 patients could initially be treated with AS, while 18,000 received the treatment in 2006, leaving an additional 70,000 patients who could be treated with the strategy but are not.
Lead study author Tomas Dvorak, MD, of the department of radiation oncology at Tufts Medical Center, noted that despite these published figures, practice patterns will be slow to change. “Treatment decisions about active surveillance versus surgery or radiation are made at the individual patient-physician level, and as long as the current health care dynamics remain the same, I doubt active surveillance will be presented as a valid treatment choice to many patients,” Dr. Dvorak. In the United States, he said, patients often want “every treatment possible for their disease,” while physicians are concerned about missing a chance to cure a patient “who might develop incurable disease during the surveillance process.” Finally, he commented that financial aspects also come into play, since physicians are not compensated for monitoring a patient.