Outcomes Good With Active Surveillance, New Study Suggests
By Miranda Hitti
WebMD Health News
Reviewed by Louise Chang, MD
March 19, 2009 -- The best treatment may be no treatment at all for some younger men with early stage, good-prognosis prostate cancer, new research suggests.
Known as active surveillance or watchful waiting, the strategy of intensive monitoring instead of treatment is mostly reserved for elderly patients with other health problems who are likely to die of some other cause before their prostate cancer spreads.
The thinking has been that the approach may be too risky for younger men who may live with prostate cancer for decades instead of a few years.
But a new study shows active surveillance to be a viable option for carefully selected prostate cancer patients, regardless of their age, as long as they are closely followed to make sure their disease does not progress.
Of the 262 men in the study who were initially observed but not treated after being diagnosed, 43 ended up needing treatment over an average follow-up of about 30 months and one patient died after his cancer spread to his bones.
"There is definitely a risk to this strategy," University of Chicago urologist and lead researcher Scott E. Eggener, MD, tells WebMD. "What we were able to do in this study was quantify this risk, and it appears to be very low."
Prostate Cancer Without Treatment
Eggener made it clear that not all prostate cancer patients with early-stage disease and a good prognosis are good candidates for active surveillance.
In the United States, one man in six will receive a diagnosis of prostate cancer during his lifetime, but a much smaller percentage -- one in 35 -- will die from the disease, according to the American Cancer Society.
"Some men may be rushing into treatment that won't necessarily benefit them, prevent problems, or prolong life," Eggener says. "Close observation in certain patients may maintain quality of life without increasing the chances of the cancer spreading."
The newly reported study included 262 prostate cancer patients recruited from four treatment centers in the United States and Canada between 1991 and 2007.
All the men were younger than 75 at recruitment, with the average age being 64. All had early-stage, localized disease and all had the most favorable biological disease markers, including a prostate-specific antigen (PSA) score of below 10 ng/mL and a Gleason score of 6 or below.
Instead of having one biopsy to determine eligibility for active surveillance, the patients had two. The second biopsy was done between 3.7-10.5 months after the first biopsy. As a result of the second biopsy, about 30% of the patients who were initially considered candidates for surveillance were excluded from the study because they ended up undergoing treatment.
"We feel that the second biopsy was an important step in identifying patients who are not good candidates for active surveillance," Eggener says.
Most Patients Did Not Progress
With active surveillance, the patients had physical exams and PSA tests every six months, with biopsies recommended every one to two years.
Over an average of two and a half years of follow-up, 43 of the study participants showed evidence of cancer progression and received treatment.
In two patients, cancer spread beyond their prostate.
The study is published in the April issue of the Journal of Urology.
The findings support the idea that some men with prostate cancer may not need treatment, American Cancer Society Deputy Chief Medical Officer Len Lichtenfeld, MD, tells WebMD.
He says the addition of a second biopsy should help refine the search for men who are appropriate candidates for active surveillance, but he also agrees that the strategy of watchful waiting is not without its risks.
"The real advance will be when we have tests that will tell us with a high degree of accuracy when treatment is needed and when it is not," he says.
A great deal of research is being done to identify genetic tests or tumor markers that can do this, but Lichtenfeld says it will be years before these tests are validated.
Eggener, S.E., Journal of Urology, April 2009; vol 181: pp 1635-1641.
Scott E. Eggener, MD, urologist, assistant professor of surgery, University of Chicago.
Len Lichtenfeld, MD, deputy chief medical officer, American Cancer Society.
American Cancer Society web site: "What Are the Key Statistics about Prostate Cancer?"
© 2009 WebMD, LLC. All rights reserved.