Expectant management remains underused for men with low-risk prostate cancer

Monitoring men with very low- and low-risk prostate cancers using watchful waiting or active surveillance, called expectant management, is a useful approach for a large number of men with localized tumors and could spare them the debilitating side effects of aggressive treatments that are too often unnecessarily used in this patient population, a UCLA review of common practices in prostate cancer has found.

Since the initiation of PSA screening tests, most men with prostate cancer are now diagnosed with localized, low-risk prostate tumors that are unlikely to kill them. However, nearly all of these men undergo surgery or radiation, putting them at risk for ongoing side effects such as erectile dysfunction and impaired urinary function. As many as 40 percent of patients may currently be overtreated, said review senior author Dr. Mark Litwin, professor and chair of UCLA Urology.

"This study is the most up-to-date and comprehensive review of expectant management of prostate cancer patients worldwide. This represents an important resource for patients and providers considering surveillance for prostate cancer," Litwin said. "Active surveillance and other observational strategies have produced excellent, long-term disease-specific survival and minimal morbidity for men with prostate cancer. Despite this, expectant management remains underused for men with localized prostate cancer."

The study appears in the July/August 2015 issue of the peer-reviewed journal CA: A Cancer Journal for Clinicians.

The review clearly lays out a number of aspects of expectant management for men with low-risk prostate cancer. First, the UCLA team clarified the definitions of types of surveillance, making it easier for physicians and their patients to decide which is best for them. Active surveillance uses repeated PSA testing and prostate biopsies to monitor for development of more aggressive disease in younger, healthier patients who might benefit from delaying treatment. Watchful waiting avoids aggressive testing and watches for any physical symptoms of progressive disease. It is generally reserved for avoiding treatment altogether for older, sicker patients who will most likely die from something else.

The review describes the current surveillance protocols, and reviews the outcomes for each of these strategies in terms of cancer survival and quality of life. Additionally the review addresses the novel technologies such as prostate MRI and fusion biopsies that may prove beneficial for surveillance patients.

"Considerable questions remain regarding both the identification of optimal candidates for surveillance, as well as understanding the ideal monitoring strategy after the initiation of observational protocols," said Dr. Leonard Marks, study co-author and a professor of urology. "Using strict inclusion criteria for very low-risk or low-risk prostates cancer can select a group of prostate cancer patients for active surveillance who would avoid the side effects of therapy while experiencing comparable survival and quality of life."

Going forward, Marks said, more work is required to optimize the delivery of these expectant management strategies for patients treated in certain settings that may not have incorporated active surveillance into their treatment repertoire. Despite increased adoption of expectant management, active surveillance still remains broadly underused and more data will be needed to clarify the factors contributing to this finding at a population level.

Prostate cancer is the most frequently diagnosed cancer in men aside from skin cancer. An estimated 233,000 new cases of prostate cancer will occur in the United States in 2015. Of those, nearly 30,000 men will die. It's estimated that more than two million prostate cancer survivors are living in the United States today.

"Ultimately, the decision-making process surrounding treatment for a man with localized prostate cancer must take an individualized approach. The risks and benefits of expectant management vis-a-vis active treatment should be reviewed with the patient in light of existing knowledge, potentially with the use of decision aids to help enable a truly shared decision-making process," the review states. "Active surveillance is a viable approach for most men with low-risk prostate cancer, and its broader adoption has the potential to stop the overtreatment of men with indolent lesions and redirect resources to men with more serious cancers."