Challenges remain for active surveillance in low-risk PCa

Author(s):

“Active surveillance continues to gain traction as a management strategy for low-risk prostate cancer in the United States. However, barriers still exist and challenges remain for both the treating urologist and the patient,” writes J. Brantley Thrasher, MD.

J. Brantley Thrasher, MD

Dr. Thrasher,

Active surveillance (AS) continues to gain traction as a management strategy for low-risk prostate cancer in the United States. However, barriers still exist and challenges remain for both the treating urologist and the patient.

Marzouk et al evaluated 463 patients enrolled in AS from March 2000 through January 2016. A total of 413 patients completed a prostate cancer quality of life survey as part of the follow-up. Questions related to the anxiety associated with their prostate cancer. Estimating equations were used to test the association between the risk of anxiety and age, marital status, PSA, Gleason sum, number of positive cores, family history, overall state of health, and length of time on AS.

The authors found that the risk of anxiety decreased over time, and those reporting high overall health scores had lower anxiety levels throughout their duration on AS. They conclude that although moderate levels of anxiety exist in patients on AS, it significantly decreases over time and this should be taken into consideration when counseling men.

This study adds to a growing body of information on how men perceive AS, its effect on their emotional well-being, and reasons they might consider leaving an AS protocol. Berger et al interviewed a small sample of the 1,159 men on the Johns Hopkins AS program who self-elected to leave (Patient 2014; 7:427-36). The authors noted that those electing to leave the program had higher baseline PSA levels and younger age. They also noted that this subset of men continued to feel anxious about their cancer and viewed AS as a way to delay treatment rather than avoid it. Additionally, the attitudes and worries of family members and loved ones were potential influences on the decision to leave the AS program.

The take-home for all of us who treat low-risk prostate cancer and use AS protocols is that we need to tailor our counseling to consider many of these factors. Family members and loved ones should be included, when possible, in the counseling session. Detailed counseling regarding the very slow growth rates of low-grade prostate cancer, the protocol for follow-up, and trigger points for further decisions/intervention should be covered and questions answered to minimize anxiety.

However, further studies are needed in this patient population to answer numerous questions: What should a standard AS protocol look like? How should contemporary imaging and genetic testing be incorporated? Should older men or those with multiple comorbidities be counseled differently than younger, healthy men? And finally, how should family members and loved ones be integrated into AS protocols?