Prostate cancer active surveillance is most appropriate for older men with low-risk disease, whereas younger men with intermediate-risk disease derive less benefit, investigators report.
Eugenio Ventimiglia, MD, of IRCCS Ospedale San Raffaele, in Milan, Italy, and colleagues created a state transition model using 1992-2014 data from Prostate Cancer data Base Sweden involving 23,655 men with very low-risk to intermediate-risk prostate cancer. Of these, 16,177 men received active surveillance and 7478 received watchful waiting. The team simulated prostate cancer trajectories up to 30 years by age group at diagnosis, prostate cancer risk category, and Charlson Comorbidity Index.
Younger men diagnosed at age 55 years who died of prostate cancer before age 85 years had the highest prostate cancer death rates: 9%, 13%, and 15% among those with very low-, low-, and intermediate-risk disease, respectively, Dr Ventimiglia’s team reported in JAMA Network Open. Older men diagnosed at age 70 years had lower prostate cancer death rates: 3%, 6%, and 7% among those with very low-, low-, and intermediate-risk disease, respectively,
The investigators also estimated patients’ remaining treatment-free life-years by age group and prostate cancer risk category. The mean proportion of remaining life-years without treatment for men diagnosed at age 55 years was 48%, 36%, and 29% for very low-, low-, and intermediate-risk prostate cancer, respectively. Men aged 70 years at diagnosis had higher mean proportions of remaining life-years without treatment: 77%, 66%, and 60% for those with very low-, low-, and intermediate-risk prostate cancer, respectively.
“The findings of this Swedish cohort study suggest that men older than 65 years with low-risk [prostate cancer] had a high proportion of treatment-free years (53%-70%) and a low risk of [prostate cancer] death (6%-8%), hence [active surveillance] was indicated among men in this subgroup,” Dr Ventimiglia’s team wrote. “In contrast, in men younger than 65 years, [active surveillance] appeared to be indicated only in those with very low-risk [prostate cancer].”
In an accompanying editorial, Ahmed O. Elmehrath, MD, of Cairo University in Egypt commented: “These results may be useful in informing clinical practice with regard to disease management and follow-up of men with [prostate cancer] regarding the optimal selection of treatment strategies and their allocation to patient populations that will benefit most from their implementation.”
The study is limited by use of a Swedish national population health registry, which unlike tertiary centers did not have stringent criteria for adoption of prostate cancer active surveillance. During the 1992-2014 study period, prostate cancer classification and indications for deferred treatment also changed.
Ventimiglia E, Bill-Axelson A, Bratt O, et al. Long-term outcomes among men undergoing active surveillance for prostate cancer in Sweden. JAMA Netw Open. Published online September 14, 2022. doi:10.1001/jamanetworkopen.2022.31015
Elmehrath AO. Exploring the long-term outcomes of active surveillance among men with prostate cancer—Best for whom? JAMA Netw Open. Published online September 14, 2022. doi:10.1001/jamanetworkopen.2022.31024