Increasing the use of active surveillance for prostate cancer in younger men

Abstract

Prostate cancer is the second most common malignancy and the fifth leading cause of cancer-related deaths in men worldwide. 1 This dichotomy in incidence and mortality is largely because of the disease's long latency period and slow growth rate, which permit early detection. Although the prevalence of prostate cancer increases with age, autopsy studies have demonstrated a relatively high rate of occult prostate cancer: from 2.8% to 35.4% in men aged 40 to 49 years and from 7.9% to 45.9% in men aged 50 to 59 years, varying by race. 2 However, the slow rate of disease progression results in many men dying of other causes. This is especially important when considering potentially compromised sexual, urinary, and bowel quality-of-life measures among men who have undergone intervention for prostate cancer. Therefore, balancing the timing of intervention in young men with low-risk, localized prostate cancer to postpone or avoid these potential side effects without comprising oncologic outcomes is an important area of active investigation.In this issue of Cancer, Mahal et al examine the national rates of conservative management for low-risk prostate cancer and their short-term outcomes in the largest cohort of men aged ≤55 years. Using the Surveillance, Epidemiology, and End Results (SEER) database, 50,302 men were evaluated between 2010 and 2015. The use of conservative management increased in men aged ≤55 years (from 8.61% to 34.56%; P < .001) and in men aged >55 years (from 15.99% to 43.81%; P < .001). Furthermore, ≤2 positive cores, higher socioeconomic status, age ≥56 years, and diagnosis after 2012 were all factors associated with conservative therapy (P < .001). Five-year prostate cancer-specific mortality rates were <0.3% across all ages irrespective of whether conservative management strategies were used. 3 Although there remains no consensus on the management of low-risk prostate cancer in young men, there is an obvious increase in the use of these conservative management strategies, which take into account these men's safety and quality of life.Conservative management is accomplished by 1 of 2 strategies: watchful waiting (WW) or active surveillance (AS). WW is generally offered to patients with shorter life expectancy and significant comorbidities. Definitive treatment options are forgone in lieu of monitoring a patient's disease progression, typically to a higher stage with metastatic spread, and palliatively managing symptoms to preserve their quality of life. Conversely, AS involves the intensive monitoring of disease progression to higher grade groups or risk strata with expectations to intervene if such progression is detected, with the goal of staving off treatment and its side effects if the disease remains indolent. These ideas are upheld by Loeb and colleagues' Markov model for men with localized prostate cancer who elected for either AS or WW. Those authors demonstrated more life-years and quality-of-life years with AS than with WW, except in patients aged >65 years or when treatment-related compli...

Integration of magnetic resonance imaging into prostate cancer nomograms

“… 37 Further considerations in assessing these models in younger men at risk for prostate cancer should be considered for the future as the decision to pursue active treatment versus AS for a newly diagnosed prostate cancer has a significant impact on their quality of life. 110 …”

“…37 Further considerations in assessing these models in younger men at risk for prostate cancer should be considered for the future as the decision to pursue active treatment versus AS for a newly diagnosed prostate cancer has a significant impact on their quality of life. 110 Unfortunately, nomograms need to be extensively validated, and re-calibrated to each new population. [111][112][113] This can be costly and timeconsuming.…”

Aktive Überwachung des Prostatakarzinoms

“…Eine Ob gegebenenfalls auf die jährlichen Kontrollbiopsien verzichtet werden kann, wurde von Armin et al untersucht [8,9,10,11]. Männer wurden einer mpMRT und Sättigungsbiopsie unterzogen, gefolgt von einer jährlichen seriellen mpMRT, bis nach 3 Jahren pro Protokoll eine erneute Sättigungsbiopsie durchgeführt wurde.…”

Magnetic resonance imaging–based risk calculators optimize selection for prostate biopsy among biopsy‐naive men

“…Furthermore, unnecessary prostate biopsies have led to the overdiagnosis of low-risk prostate cancer, which places an undue psychological burden on patients, and to potentially unnecessary active treatment. 1,2 Therefore, there is a significant push to better identify men who harbor clinically significant prostate cancer (csPCa; grade group ≥ 2) for prostate biopsy. To address this difficult clinical question, risk calculators have been created on the basis of predictive modeling to aid clinicians and patients in deciding whether to pursue prostate biopsy.…”

“…However, prostate biopsy is an invasive diagnostic procedure with well‐established risks, including hematuria, urinary tract infections, anal bleeding, and sepsis. Furthermore, unnecessary prostate biopsies have led to the overdiagnosis of low‐risk prostate cancer, which places an undue psychological burden on patients, and to potentially unnecessary active treatment 1,2 . Therefore, there is a significant push to better identify men who harbor clinically significant prostate cancer (csPCa; grade group ≥ 2) for prostate biopsy.…”