The Use and Short-term Outcomes of Active Surveillance in Men With National Comprehensive Cancer Network Favorable Intermediate-risk Prostate Cancer: The Initial Michigan Urological Surgery Improvement Collaborative Experience

Abstract

Study Need and Importance:There is a lack of realworld evidence on the use of active surveillance (AS) for favorable intermediate-risk prostate cancer (FIRPC) from diverse clinical practice settings. Further, little is known about the short-term oncologic outcomes for men with FIRPC who receive up-front treatment vs those who delay radical prostatectomy (RP). We retrospectively reviewed the Michigan Urological Surgery Improvement Collaborative data to assess the use of AS for men diagnosed with FIRPC and investigated short-term outcomes including adverse pathology and time to biochemical recurrence for those who underwent radical prostatectomy from 2012 to 2020. What We Found: We found considerable variability in the use of AS for men with FIPRC by practice ranging from 8% to 65% (23% to 85% for Grade Group [GG] 1 and 8% to 57% for GG2 disease). The 5-year treatment-free probability for those managed with AS was 63% overall and 73% for GG1 and 57% for GG2 disease. In risk-adjusted models, men with delayed RP had a higher risk of adverse pathology (46% vs 32%) but had similar rates of biochemical recurrence (22% vs 14%) to those who received immediate treatment (see Figure ). Limitations: The present study has limitations that are inherent to observational designs, including selection bias. Since the Michigan Urological Surgery Improvement Collaborative is a relatively new surgical registry, we were limited to reporting shortterm oncologic outcomes for surgical patients only.Other limitations include lack of standardization in AS follow-up care as well as the inconsistent criteria for transition from AS to treatment. Interpretation for Patient Care: Our study shows that men who delayed RP had similar oncologic outcomes to men undergoing up-front treatment suggesting many men with FIRPC can safely avoid radical treatment for years without compromising the survival benefit associated with radical treatment.

Co‐designing an online treatment decision aid for men with low‐risk prostate cancer: Navigate

“…In the period of time during which Navigate has been developed, AS is increasingly being used for favourable intermediate-risk PC. 31 While Navigate was initially designed with and for men with LRPC, it is equally relevant for men with intermediate risk PC, and this cohort of men is included in the current RCT. Report the source of funding to develop the patient decision aid and whether funders, authors or their affiliations, stand to gain or lose by choices patients make after using the patient decision aid…”

Editorial Comment to “A national questionnaire survey of Japanese urologists on active surveillance for low‐ and intermediate‐risk prostate cancer”

“…Interestingly, the finding of this survey suggest that AS may be conducted for favorable intermediate-risk prostate cancer in a certain percentage of patients in Japan as it is in the United States. 2,5 The results of this survey highlight several problems regarding the extent of AS usage in Japan. Some respondents indicate that the upper age limit for AS is 90 years or older.…”

“…Furthermore, they reported that about 40% of urologists considered AS for favorable intermediate‐risk patients. Interestingly, the finding of this survey suggest that AS may be conducted for favorable intermediate‐risk prostate cancer in a certain percentage of patients in Japan as it is in the United States 2,5 …”

“…1 According to recent realworld data from the United States, the use of AS for favorable intermediate-risk prostate cancer patients would gradually increase from 13% in 2012 to 45% in 2020. 2 However, in the report from Japan by Nakai et al, only 5.8% of patients classified as intermediate-risk, and 32.5% of those classified as very-low or low-risk received AS or watchful waiting (WW) between 2013 and 2015. 3 In Japan, even in 2022, is there still not much AS being conducted to low-risk or favorable intermediate-risk patients?…”

“…In the National Comprehensive Cancer Network (NCCN) guidelines, active surveillance (AS) is currently the preferred primary management strategy for most patients with low‐risk prostate cancer, and it is also given in the same category of recommendation as surgery and radiation therapy for favorable intermediate‐risk disease 1 . According to recent real‐world data from the United States, the use of AS for favorable intermediate‐risk prostate cancer patients would gradually increase from 13% in 2012 to 45% in 2020 2 . However, in the report from Japan by Nakai et al., only 5.8% of patients classified as intermediate‐risk, and 32.5% of those classified as very‐low or low‐risk received AS or watchful waiting (WW) between 2013 and 2015 3 .…”