Many low-risk PCa patients on AS may be lost to follow-up

“Journal Article of the Month” is a new Urology Times section in which Badar M. Mian, MD (left), offers perspective on noteworthy research in the peer-reviewed literature.  Dr. Mian is associate professor of surgery in the division of urology at Albany Medical College, Albany, NY.

Active surveillance (AS) for prostate cancer is included in virtually all the guidelines, and its use has been increasing steadily over the last decade. AS, requiring follow-up testing, has become the current standard of care for men with low-risk prostate cancer. According to Ginsburg et al, many men on AS are lost to follow-up and thus at potentially increased risk for disease progression and poor outcomes (Eur Urol 2018; 74:704-7).

The authors analyzed data in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) registry, which includes patients with prostate cancer from 44 academic and community urology practices. For this study, they included those patients whose managing physician had recorded AS as the initial management strategy in the medical records.

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Over a 6-year period from 2011 to 2017, there were 2,211 patients who were initially identified as being managed with AS. The median surveillance period was 32.1 months. The median age was 66.2 years, and other clinical and demographic characteristics were in line with other published reports. Lost to follow-up (LTFU) status was defined as a period of at least 18 months without any surveillance testing such as PSA, imaging, or prostate biopsy entered into the registry or medical record.

10% of patients lost to follow-up

The authors identified 217 patients (10%) as LTFU during a median follow-up of 32.1 months. African-American men and those with higher Charlson comorbidity index were associated with increased risk of LTFU. Most of the LTFU cases (126/217, 58%) occurred soon after or in the first 6 months after being identified as AS candidates in the registry. Also, there was wide variability in LTFU-free probability among different practices ranging from 52% to 99%.

Continue to the next page for more.AS protocols in use today are designed with variable intervals for PSA testing and prostate biopsy (and magnetic resonance imaging) to capture any progression in the grade/stage of cancer in a timely fashion. This study does not provide information on the recommended frequency of monitoring tests, but it’s safe to assume that heterogeneity existed across various study practice sites.

Further, almost 20% of patients in this AS cohort had Gleason score 7-10 prostate cancer. Some of these patients were likely poor candidates for early treatment due to comorbidities and may have been on a watchful waiting approach instead of a rigorous AS protocol. Also, it’s possible that some men sought care at a practice that is not part of MUSIC.

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It’s important to remember that missing some monitoring tests over a relatively short period of time does not necessarily result in metastases or death from these cancers with a long natural history. Still, there is some concern based on published reports that a few men who are initially managed with AS may experience disease progression and lose the window of curability.

The data presented here in regards to LTFU do not question the safety or ­feasibility of AS, but this study highlights the need for each practice to perform a self-audit of its AS protocol and take all necessary measures to ensure that patients are not lost during the monitoring period.