Active surveillance for low-risk localized prostate cancer: what do men and their partners think?

Abstract Background. Active surveillance (AS) is recognized as a reasonable treatment option for low-risk localized prostate cancer (LPC) but continues to be chosen by a minority of men. To date, limited data are available regarding reasons why men with low-risk LPC adopt AS. Purpose. The aim of this study is to better understand conceptualizations, experiences and reasons why men with low-risk LPC and their partners adopt AS. Methods. We conducted five focus groups (FGs), three among men with low-risk LPC who had chosen AS and two with their partners. FGs were video/audio recorded, transcribed and analysed using qualitative thematic analysis. Results. A total of 12 men and 6 partners (all women) participated in FG discussions. The most common reasons for choosing AS were seeing the LPC as ‘small’ or ‘low grade’ without need for immediate treatment and trusting their physician’s AS recommendation. The most common concerns about AS were perceived unreliability of prostate specific antigen, pain associated with prostate biopsies and potential cancer progression. Partners saw themselves as very involved in their husbands’ treatment decision-making process, more than men acknowledged them to be. Multiple terms including ‘watchful waiting’ were used interchangeably with AS. There appeared to be a lack of understanding that AS is not simply ‘doing nothing’ but is actually a recognized management option for low-risk LPC. Conclusions. Emphasizing the low risk of a man’s LPC and enhancing physician trust may increase acceptability of AS. Standardizing terminology and presenting AS as a reasonable and recognized management option may also help increase its adoption.

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Overdiagnosis and Overtreatment of Prostate Cancer

American Society of Clinical Oncology Educational Book ◽

10.14694/edbook_am.2012.32.98 ◽

2012 ◽

pp. e35-e39 ◽

Cited By ~ 4

Author(s):

Ian M. Thompson

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Specific Antigen ◽

The United States ◽

Assessment Tools ◽

Low Grade ◽

High Grade ◽

Surveillance Strategy ◽

Psa Testing ◽

Prostate Cancer Prevention

Overview: Prostate cancer is a ubiquitous disease, affecting as many as two-thirds of men in their 60s. Through widespread prostate-specific antigen (PSA) testing, increasing rates of prostate biopsy, and increased sampling of the prostate, a larger fraction of low-grade, low-volume tumors have been detected, consistent with tumors often found at autopsy. These tumors have historically been treated in a manner similar to that used for higher-grade tumors but, more recently, it has become evident that with a plan of active surveillance that reserves treatment for only those patients whose tumors show evidence of progression, very high disease-specific survival can be achieved. Unfortunately, the frequency of recommendation of an active surveillance strategy in the United States is low. An alternative strategy to improve prostate cancer detection is through selected biopsy of those men who are at greater risk of harboring high-grade, potentially lethal cancer. This strategy is currently possible through the use of risk assessment tools such as the Prostate Cancer Prevention Trial Risk Calculator ( www.prostate.cancer.risk.calculator.com ) as well as others. These tools can predict with considerable accuracy a man's risk of low-grade and high-grade cancer, allowing informed decision making for the patient with a goal of detection of high-risk disease. Ultimately, other biomarkers including PCA3, TMPRSS2:ERG, and [-2]proPSA will likely aid in discriminating these two types of cancer before biopsy.

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Determinants for choosing and adhering to active surveillance for localised prostate cancer: a nationwide population-based study

BMJ Open ◽

10.1136/bmjopen-2019-033944 ◽

2019 ◽

Vol 9 (12) ◽

pp. e033944

Author(s):

Oskar Bergengren ◽

Hans Garmo ◽

Ola Bratt ◽

Lars Holmberg ◽

Eva Johansson ◽

...

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Specific Antigen ◽

Healthcare Providers ◽

Population Based ◽

Low Risk ◽

Population Based Study ◽

Factors Associated ◽

Comorbidity Index ◽

Main Factor

ObjectiveKnowledge about factors influencing choice of and adherence to active surveillance (AS) for prostate cancer (PC) is scarce. We aim to identify which factors most affected choosing and adhering to AS and to quantify their relative importance.Design, setting and participantsIn 2015, we sent a questionnaire to all Swedish men aged ≤70 years registered in the National Prostate Cancer Register of Sweden who were diagnosed in 2008 with low-risk PC and had undergone prostatectomy, radiotherapy or started on AS.Outcome measurements and statistical analysisLogistic regression was used to calculate ORs with 95% CIs for factors potentially affecting choice and adherence to AS.Results1288 out of 1720 men (75%) responded, 451 (35%) chose AS and 837 (65%) underwent curative treatment. Of those starting on AS, 238 (53%) diverted to treatment within 7 years. Most men (83%) choose AS because ‘My doctor recommended AS’. Factors associated with choosing AS over treatment were older age (OR 1.81, 95% CI 1.29 to 2.54), a Charlson Comorbidity Index >2 (OR 1.50, 95% CI 1.06 to 2.13), being unaccompanied when notified of the cancer diagnosis (OR 1.45, 95% CI 1.11 to 1.89). Men with a higher prostate-specific antigen (PSA) at the time of diagnosis were less likely to adhere to AS (OR 0.26, 95% CI 0.10 to 0.63). The reason for having treatment after initial AS was ‘the PSA level was rising’ in 55% and biopsy findings in 36%.ConclusionsA doctor’s recommendation strongly affects which treatment is chosen for men with low-risk PC. Rising PSA values were the main factor for initiating treatment for men on AS. These findings need be considered by healthcare providers who wish to increase the uptake of and adherence to AS.

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4284 Development of a Survey Instrument to Predict Uptake of and Adherence to Active Surveillance among Men with Low-Risk Prostate Cancer

Journal of Clinical and Translational Science ◽

10.1017/cts.2020.383 ◽

2020 ◽

Vol 4 (s1) ◽

pp. 128-129

Author(s):

Aaron T Seaman ◽

Kathryn L. Taylor ◽

Kimberly Davis ◽

Kenneth G. Nepple ◽

Michelle A. Mengeling ◽

...

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Cancer Progression ◽

Large Scale ◽

Survey Instrument ◽

Low Risk ◽

Cognitive Interviews ◽

Risk Prostate Cancer ◽

Low Risk Prostate Cancer ◽

Single Instrument

OBJECTIVES/GOALS: Active surveillance (AS) is a recognized strategy to manage low-risk prostate cancer (PCa) in the absence of cancer progression. Little prospective data exists on the decisional factors associated with selecting and adhering to AS in the absence of cancer progression. We developed a survey instrument to predict AS uptake and adherence. METHODS/STUDY POPULATION: We utilized a three-step process to develop and refine a survey instrument designed to predict AS uptake and adherence among men with low-risk PCa: 1) We identified relevant conceptual domains based on prior research and a literature review. 2) We conducted 21 semi-structured concept elicitation interviews to identify patient-perceived barriers and facilitators to AS uptake and adherence among men with a low-risk PCa who had been on AS for ≥1 year. The identified concepts became the basis of our draft survey instrument. 3) We conducted two rounds of cognitive interviews with men with low-risk PCa (n = 12; n = 6) to refine and initially validate the instrument. RESULTS/ANTICIPATED RESULTS: Relevant concepts identified from the initial interviews included the importance of patient: knowledge of their PCa risk, value in delaying treatment, trust in urologist and the AS surveillance protocol, and perceived social support. Initially, the survey was drafted as a single instrument to be administered after a patient had selected AS comprising sections on patient health, AS selection, and AS adherence. Based on the first round of cognitive interviews, we revised the single instrument into two surveys to track shifts in patient preference and experience. The first, administered at diagnosis, focuses on selection, and the second, a 6-month follow up, focuses on adherence. Following revisions, participants indicated the revised 2-part instrument was clear and not burdensome to complete. DISCUSSION/SIGNIFICANCE OF IMPACT: The instrument’s content validity was evaluated through cognitive interviews, which supported that the survey items’ intended and understood meanings were isomorphic. In the next phase, we plan to conduct a large-scale prospective cohort study to evaluate the predictive validity, after which it will be available for public research use.

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Multiparametric prostate MRI and MRI/ultrasound fusion biopsy as tools to follow prostate cancer progression for men on active surveillance.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.4_suppl.63 ◽

2014 ◽

Vol 32 (4_suppl) ◽

pp. 63-63 ◽

Cited By ~ 2

Author(s):

Nabeel Shakir ◽

Annerleim Walton-Diaz ◽

Soroush Rais-Bahrami ◽

Baris Turkbey ◽

Jason Rothwax ◽

...

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Cancer Progression ◽

Predictive Value ◽

Low Risk ◽

Fusion Biopsy ◽

Trus Biopsy ◽

Risk Prostate Cancer ◽

Low Risk Prostate Cancer

63 Background: Active surveillance (AS) is an option for patients with low risk prostate cancer (PCa); however, determining disease progression is challenging. At the NCI, multiparametric MRI (MP-MRI) with our biopsy protocol (MR-US fusion-guided plus 12 core extended sextant biopsy) has been used to confirm eligibility for AS. We evaluated the utility of these modalities in monitoring patients on AS. Methods: Patients who underwent MP-MRI of the prostate with biopsy per our protocol between 2007-2012 were reviewed. We selected a subset who met Johns Hopkins criteria for AS (Gleason score≤6, PSA density≤0.15, tumor involvement of ≤2 cores, and ≤50% of any single core) by outside 12−core TRUS biopsy. Patients with Gleason score≤6 confirmed at first NCI biopsy session were followed with annual MP-MRI and biopsy. MRI progression was defined as an increase in MP-MRI suspicion level, lesion diameter, or number of lesions. Pathologic progression was defined as an increase to Gleason score≥7 in either 12-core or MR-fusion biopsy. We determined the association between MRI and pathologic progression. Results: 129 patients met JHU criteria for AS by outside biopsy. Mean age was 61.6 years and mean PSA 5.16ng/mL. 28/129 (21.7%) patients had Gleason score ≥7 at first NCI biopsy session.31 patients had at least two biopsy sessions (mean follow up 18 months, range 12-54 months) of which 9/31 (29%) increased in Gleason score, all to 3+4=7. Fusion biopsy detected more pathologic progression than did standard biopsy (Table). The positive predictive value of MP-MRI for pathologic progression was 50%, while the negative predictive value was 84%. The sensitivity and specificity of MP-MRI for increase in Gleason score was 67% and 73%, respectively. Conclusions: Stable findings on MP-MRI are associated with Gleason score stability in patients with low-risk PCa choosing AS. The majority of patients who had pathologic progression were detected on fusion biopsy, which may suggest that random biopsies are unnecessary in this population. Larger studies are needed to validate these findings. [Table: see text]

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Gleason score upgrade among 10,282 men who underwent surgery as initial treatment in 2010: A population-based study.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.4_suppl.72 ◽

2014 ◽

Vol 32 (4_suppl) ◽

pp. 72-72

Author(s):

Hong Zhang ◽

Edward M. Messing ◽

Hamza Ahmed ◽

Yuhchyau Chen

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Specific Antigen ◽

Low Risk ◽

Categorical Variables ◽

Intermediate Risk ◽

Time Of Surgery ◽

Significant Difference ◽

Risk Prostate Cancer

72 Background: Active surveillance is now accepted initial management for men who have localized prostate cancer with low risk of disease progression. Many criteria have been used for patient identification, including Gleason score (GS) obtained from prostate biopsy. Because of concerns of sampling error, some have recommended repeated biopsy before committing to active surveillance. However, there is limited information about the risk of missing high grade disease using the current standard biopsy approach. This study seeks to compare GS difference from biopsy and surgery to provide an estimated rate of GS upgrade. Methods: The Surveillance, Epidemiology, and End Results (SEER) program was used to identify men with American Joint Committee on Cancer stage T1-2cN0M0 prostate cancer diagnosed between January 2010 and December 2010. Patients who underwent prostatectomy were selected for further analysis. Based on prostate-specific antigen (PSA) levels and GS, cases were divided into low (PSA <=10 and GS <=6) and intermediate (10<PSA<=20 or GS=7) risk groups. The rates of GS upgrade were reported for each group. Chi-square tests were used to assess differences in categorical variables (e.g. age and race) between groups of GS upgrade and no change/downgrade. Results: A total of 10,282 men were evaluated, with 9.2% (n=942) having low-risk disease, and 90.8% (n=9340) having intermediate-risk disease. Among men with low-risk prostate cancer, 22.3% (n=210) had GS upgrade and 0.8% (n=8) had GS 8 disease. Among men with intermediate risk disease, 26.2% (n=2446) had GS upgrade and 2.3% (n=214) had GS 8 disease. There was no statistically significant difference in either age or race distribution among men who had GS upgrade versus no change or downgrade at the time of surgery. Conclusions: A substantial number of low- and intermediate-risk prostate cancer patients had GS upgrade at the time of surgery, but few had upgraded to GS 8 high risk disease. These observations suggest that repeat biopsy prior to active surveillance may not be necessary.

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Active surveillance for early stage prostate cancer: What do men and their partners think?

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.3_suppl.95 ◽

2016 ◽

Vol 34 (3_suppl) ◽

pp. 95-95

Author(s):

Jinping Xu ◽

Arun Mallapareddi ◽

Julie Ruterbusch ◽

Elyse Reamer ◽

Susan Eggly

Keyword(s):

Prostate Cancer ◽

Focus Groups ◽

Active Surveillance ◽

Early Stage ◽

Treatment Decision ◽

Low Risk ◽

Physical And Mental Health ◽

Current Function ◽

Physician Trust ◽

Qualitative Thematic Analysis

95 Background: Despite growing recognition over the last decade that active surveillance (AS) is a reasonable management option for men diagnosed with localized prostate cancer (LPC), only a minority of men choose AS. This study examines the conceptualizations, experiences, and reasons for choosing AS among men with LPC and their partners. Methods: We conducted three focus groups with men with LPC who had chosen AS (7 black, 5 white) and two focus groups with their partners (all women, 2 black, 4 white). Men were identified from a cancer registry or from an academic urologists’ practice. Focus groups were video/audio recorded, transcribed and analyzed using qualitative thematic analysis. Results: Men’s median time on AS was 18 months (range 6-72) and median age was 61 years (range 47-71). Men used many different terms (mostly “wait and see”) to describe similar AS protocols. AS was seen as delaying unnecessary treatment and keeping current function with curable treatment available later if needed. Black men mentioned concerns that some physicians profit by providing unnecessary treatments. Reasons for choosing AS included seeing their cancer as “small” or “low-risk” and trusting their physician’s advice/monitoring, despite reported concerns about PSA being an unreliable test and painful biopsies. Men recognized, but were comfortable with, the small but real threat their cancer could grow. Men found they had to justify their choice to other family members, even when their partners were supportive. Partners saw themselves as very involved and influential in the treatment decision. They were comfortable with AS because of their trust in physicians. Partners believed they know their husband’s physical and mental health better than the men themselves. Conclusions: Physician trust and description of the cancer as low-risk were the most cited reasons for adopting AS. Emphasizing the low-risk nature of the cancer and enhancing physician trust may increase the acceptability of AS.

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Prostate-specific antigen doubling time as a progression criterion in an active surveillance programme for patients with localized prostate cancer

BJU International ◽

10.1111/bju.12367 ◽

2013 ◽

Vol 113 (5b) ◽

pp. E98-E105 ◽

Cited By ~ 10

Author(s):

Frederik Birkebaek Thomsen ◽

Ib Jarle Christensen ◽

Klaus Brasso ◽

Martin Andreas Røder ◽

Peter Iversen

Keyword(s):

Prostate Cancer ◽

Prostate Specific Antigen ◽

Active Surveillance ◽

Doubling Time ◽

Specific Antigen ◽

Localized Prostate Cancer ◽

Surveillance Programme

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LOW-RISK LOCALIZED PROSTATE CANCER: ARE WE READY TO TELL PATIENTS THAT ACTIVE SURVEILLANCE IS THE PREFERRED OPTION?

BJU International ◽

10.1111/j.1464-410x.2008.07848.x ◽

2008 ◽

Vol 102 (8) ◽

pp. 923-926 ◽

Cited By ~ 2

Author(s):

Simon F. Brewster

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Low Risk ◽

Localized Prostate Cancer

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Active Surveillance for the Management of Localized Prostate Cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology Clinical Practice Guideline Endorsement

Journal of Clinical Oncology ◽

10.1200/jco.2015.65.7759 ◽

2016 ◽

Vol 34 (18) ◽

pp. 2182-2190 ◽

Cited By ~ 145

Author(s):

Ronald C. Chen ◽

R. Bryan Rumble ◽

D. Andrew Loblaw ◽

Antonio Finelli ◽

Behfar Ehdaie ◽

...

Keyword(s):

Prostate Cancer ◽

Clinical Practice ◽

Clinical Oncology ◽

Active Surveillance ◽

Gleason Score ◽

Cancer Care ◽

Specific Antigen ◽

Localized Prostate Cancer ◽

Risk Category ◽

American Society

Purpose To endorse Cancer Care Ontario’s guideline on Active Surveillance for the Management of Localized Prostate Cancer. The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for endorsing clinical practice guidelines developed by other professional organizations. Methods The Active Surveillance for the Management of Localized Prostate Cancer guideline was reviewed for developmental rigor by methodologists. The ASCO Endorsement Panel then reviewed the content and the recommendations. Results The ASCO Endorsement Panel determined that the recommendations from the Active Surveillance for the Management of Localized Prostate Cancer guideline, published in May 2015, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the Active Surveillance for the Management of Localized Prostate Cancer guideline with added qualifying statements. The Cancer Care Ontario recommendation regarding 5-alpha reductase inhibitors was not endorsed by the ASCO panel. Recommendations For most patients with low-risk (Gleason score ≤ 6) localized prostate cancer, active surveillance is the recommended disease management strategy. Factors including younger age, prostate cancer volume, patient preference, and ethnicity should be taken into account when making management decisions. Select patients with low-volume, intermediate-risk (Gleason 3 + 4 = 7) prostate cancer may be offered active surveillance. Active surveillance protocols should include prostate-specific antigen testing, digital rectal examinations, and serial prostate biopsies. Ancillary radiologic and genomic tests are investigational but may have a role in patients with discordant clinical and/or pathologic findings. Patients who are reclassified to a higher-risk category (Gleason score ≥ 7) or who have significant increases in tumor volume on subsequent biopsies should be offered active therapy.

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