Active surveillance a reasonable approach for patients with low-risk prostate cancer

Many men with low-risk, localized prostate cancers can safely choose active surveillance or “watchful waiting” instead of undergoing immediate treatment and have better quality of life while reducing health care costs, according to a new study.

In their recent publication in the Annals of Internal Medicine (2013;158(12):853-860), the authors stated that their statistical models showed that “observation is a reasonable and, in some situations, cost-saving alternative to initial treatment" for the estimated 70% of men whose cancer is classified as low-risk at diagnosis.

Julia Hayes, MD, of Dana-Farber Cancer Institute in Boston, Massachusetts, led the study. The findings support observation, including active surveillance and watchful waiting, as a reasonable and underused option for men with low-risk disease.

"About 70% of men in this country [with prostate cancer] have low-risk prostate cancer, and it's estimated that 60% of them are treated unnecessarily" with various forms of radiation or having the disease removed with radical prostatectomy surgery, said Hayes. A clinical trial called PIVOT reported that such men had about the same small risk of death over a 12-year period whether they underwent radical prostatectomy or simply observation.

Hayes and her co-authors created mathematical models to construct a variety of scenarios, focusing on men age 65 or 75 years at diagnosis, and including estimated costs associated with treatment and different forms of observation.

In active surveillance (AS), patients undergo blood tests for prostate specific antigen (PSA) every 3 months, rectal examinations every 6 months, and a prostate gland biopsy at 1 year and then every 3 years. If the tests find the cancer is more aggressive than originally thought, the patients begin treatment aimed at curing the disease. "This approach could also be described as deferred treatment," said Hayes.

A patient who chooses watchful waiting (WW) is observed without intensive monitoring and is given palliative treatment when the cancer becomes symptomatic.

Treatments for low-risk prostate cancer include radical prostatectomy, intensity-modulated radiation therapy (IMRT), or brachytherapy (radioactive seed implants.)

The investigators calculated the quality-adjusted life expectancy (QALE) for the different strategies. (QALE takes into account both the years of life gained and factors that reduce quality of life such as undergoing invasive tests, the impact of treatment and complications, and disease recurrence.) The researchers also estimated the lifetime costs of each strategy, which ranged from $18,302 for active surveillance for men age 75 years to $48,699 for a 65-year-old patient treated with IMRT therapy.

The bottom line result was that observation was more effective and in some cases less costly than initial treatment for low-risk prostate cancers. Watchful waiting yielded 11 months additional QALE over brachytherapy—the most effective treatment—and 13 months additional QALE over radical prostatectomy, the least effective treatment.

Hayes said, "it appears that active surveillance and watchful waiting are safe alternatives to initial treatment for prostate cancer based on these assumptions. But it's important to emphasize that these decisions are very much a matter of individual choice."
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