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Active Surveillance for Low-Risk Prostate Cancer: A Long-Term Strategy

Core Concepts
Active surveillance for low-risk prostate cancer is a complex strategy with varying outcomes and considerations.
Seventeen years ago, Philip Segal opted for active surveillance for Gleason 6 prostate cancer, maintaining it for peace of mind. In contrast, Bruno Barrey transitioned to radiation therapy after a follow-up biopsy revealed more advanced lesions. The approach's duration varies based on multiple factors, including cancer volume, PSA levels, and geographic location. Dropout rates from active surveillance have decreased with the adoption of MRI for staging, leading to more accurate diagnoses and treatment decisions. However, the decline in screening following recommendations against PSA testing may contribute to the rise in late-stage prostate cancer diagnoses. Urologists hold differing views on active surveillance, with some cautioning against it due to potential risks and others advocating for a partnership approach with patients.
Rashid Sayyid, MD, found that nearly two-thirds of men abandon active surveillance at 10 years. A 2023 study in JNCI Cancer Spectrum showed a decline in grade group 1 patients on active surveillance from 45% in 2010 to 25% in 2019. A 2023 study using the National Cancer Database found a decrease in patients with grade group 1 in biopsies from 45% in 2010 to 25% in 2019.
"I consider active surveillance a foolish strategy or, at best, a short-term strategy for young, otherwise healthy men, especially those having any Gleason pattern 4 disease." - William Catalona, MD "I would counsel an eligible patient considering active surveillance that at the current time, I see no strong reason why you should be subjected to treatment and the associated side effects." - Rashid Sayyid, MD

Deeper Inquiries

What societal factors influence the perception of active surveillance for prostate cancer?

The perception of active surveillance for prostate cancer is influenced by various societal factors. One key factor is the cultural attitude towards cancer and treatment. In some societies, there may be a stigma attached to cancer, leading individuals to opt for immediate treatment rather than surveillance. Additionally, societal norms around masculinity and health-seeking behavior can impact how men view active surveillance. The availability of information and education about prostate cancer in the community also plays a role in shaping perceptions. Misconceptions or lack of awareness about the benefits of active surveillance may lead to reluctance in choosing this approach.

Is there a potential downside to the increasing use of MRI in prostate cancer diagnosis and treatment?

While MRI has revolutionized the diagnosis and treatment of prostate cancer, there are potential downsides to its increasing use. One concern is the possibility of overdiagnosis and overtreatment. The high sensitivity of MRI may lead to the detection of clinically insignificant tumors that would not have caused harm if left untreated. This can result in unnecessary biopsies, treatments, and associated side effects for patients. Additionally, the cost of MRI and the expertise required to interpret the results may limit access for some patients, leading to disparities in care. There is also a risk of false positives or false negatives with MRI, which can impact treatment decisions and outcomes.

How can the healthcare system better support patients on active surveillance for prostate cancer?

To better support patients on active surveillance for prostate cancer, the healthcare system can implement several strategies. Firstly, healthcare providers should ensure thorough patient education about the benefits and risks of active surveillance compared to immediate treatment options. Shared decision-making between patients and providers is crucial in determining the most suitable approach for each individual. Regular monitoring and follow-up appointments are essential to track disease progression and provide psychological support to patients. Access to multidisciplinary care teams, including urologists, oncologists, and mental health professionals, can address the holistic needs of patients on active surveillance. Additionally, the healthcare system should prioritize research on improving risk stratification tools and surveillance protocols to enhance the effectiveness of active surveillance programs.