|The following article is part of conference coverage from the 2018 Large Urology Group Practice Association meeting in Chicago, November 1-3. Renal and Urology News’ staff will be reporting on presentations dealing with various practice management and clinical topics aimed at community-based urologists. Check back for the latest news from LUGPA 2018.|
CHICAGO—Real-world evidence from a large contemporary cohort of men on active surveillance (AS) for prostate cancer (PCa) provides reassurance that disease characteristics are driving how PCa patients are managed rather than socioeconomic factors, Jeremy Shelton, MD, MSHS, Assistant Professor of Urology at the University of California, Los Angeles, told attendees at the 2018 annual meeting of the Large Urology Group Practice Association.
The findings are from an analysis of data from a retrospective review of charts from 557 patients placed on AS for localized PCa during 2013 and early 2014 at 9 large urology practices around the United States. The cohort is notable for its size, which is comparable to that of AS cohorts at major academic centers (“a little bit smaller, but in the same ballpark”) and because of how contemporary it is, Dr Shelton told Renal & Urology News.
After a 3-year follow-up, 89% of the initial cohort was still receiving care at the diagnosing practice. Only 11% of patients were lost to follow-up, a proportion that Dr Shelton said he thought was low given that it is not uncommon for patients’ insurance plans change, for people move to different communities, among other reasons for changing providers.
At 3⅓ years, 68% of the 591 patients remained on AS and 32% went off, 57% had a repeat biopsy, and 21% had some kind of genetic testing to help stratify their risk of progression.
Among men who discontinued AS, similar numbers of patients underwent surgery and radiation (48% vs. 52% respectively).
“People received treatment as one would expect by their disease and staging characteristics,” Dr Shelton said.
The most common reason for men to go off AS was a rise in Gleason score on repeat biopsy (55% of cases), a rising PSA (15%), increase in disease volume (14%), and concerning findings on genetic testing (0.6%). No documented reason was available for 13.9%.
“This work suggests that basic clinical factors predict adherence to active surveillance and we demonstrate that in the real world, it appears that patients are being managed by disease characteristics as opposed to socioeconomic characteristics,” Dr Shelton said.
Although only a small percentage of the cohort had intermediate-risk disease, Dr Shelton said he believes AS can be an option for these patients if they have favorable characteristics, such as Gleason 3+4 disease.
Dr Shelton said advances in magnetic resonance imaging and genetic testing “will make AS even more safe and effective because of improved risk stratification.”
Although AS may be seen as more risky for younger men because of their longer life expectancy, Dr. Shelton said “the evidence from other studies suggest that they do fine.”
“Personally, I favor following younger patients more closely, potentially with regular repeat biopsies in addition to routine PSA and DRE, as well as utilizing genetic profiling and possibly MRI imaging, but the precise role and timing of these tools remains to be fully elucidated.”