Active surveillance, deferred treatment, and outcomes among a ...

Based on an average (median) follow-up of 6.0 years from diagnosis, nearly half of all men diagnosed in the G?teborg (Swedish) cohort of the European Randomized Study of Screening for Prostate Cancer (ERSCP) and managed with active surveillance have have been successfully managed without further intervention to date. ? Only 9 percent of the patients actually showed clear signs of disease progression during the follow-up period.

Godtman et al. examined data from all patients diagnosed with prostate cancer in the G?teborg cohort of the ERSCP and identified all the men who were initially managed with an active monitoring protocol. They then set out to assess the success of this form of management in this subgroup of patients identified through a mass, population-based screening strategy.

After initial diagnosis, patients were re-assessed at intervals ranging from 3 to 12 months. Patients were advised to undergo deferred active treatment if there was clear evidence of progression based on PSA level, grade, or clinical stage. (Note that the abstract of this paper does not list the criteria for such clear evidence of progression, but this is probably given in the main text; for progression by grade, this is almost certainly a Gleason score of ? 7 on re-biopsy; for progression by clinical stage, it is almost certainly a clinical stage of ? T2b ? up from ? T2a; progression based on PSA data can be more controversial.)

Here are their findings:

• 968 men were diagnosed with screen-detected prostate cancer between 1995 and 2010 in the G?teborg randomized, population-based screening trial.
• 439/968 diagnosed patients (45.4 percent) were initially managed with active surveillance.
• The median age of these 439 men was 65.4 years.
• The median follow-up period was 6.0 years from diagnosis.
• 60 percent of the 439 men initially managed with active surveillance had either low-risk or very low-risk disease.
• Just 39/439 patients (8.9 percent) clearly progressed on active surveillance.
• 162/439 patients (36.9 percent) switched from active surveillance to deferred active treatment.
  • 39/162 switched because of disease progression
  • 123/162 switched because of personal choice
• Only 1/439 patients (0.2 percent) died of prostate cancer during follow-up.
• Only 1/439 patients (0.2 percent) developed metastatic prostate cancer during follow-up.
• Projected 10-year survival data for the entire group of 439 patients are
  • Overall (all-cause) survival, 81.1 percent
  • Treatment-free survival, 45.5 percent
  • Progression-free survival survival, 86.4 percent
• Compared to the men initially diagnosed with very low-risk tumors at diagnosis
  • Men with low-risk tumors had a hazard ratio [HR] for biochemical failure of 2.1 (p = 0.09)
  • Men with intermediate-risk tumors had an HR for biochemical failure of 3.6 (p = 0.002).
  • Men with high-risk tumors had an HR for biochemical failure of 4.6 (p = 0.15).

The authors acknowledge that this study is based on a relatively short follow-up period. However, this does not mean that these results are not encouraging. Since death from prostate cancer is inevitably preceded by metastasis of the disease, we have to assume that the man who died of prostate cancer and the man who had metastatic disease are the same individual (who was initially diagnosed with intermediate-risk prostate cancer).

Godtman et al. conclude that, ?A large proportion of men with screen-detected [prostate cancer] can be managed with {active surveillance]. They go on to? note that active surveillance appears to be a safe management option for men with low- and very low-risk prostate cancer.

It is interesting to The ?New? Prostate Cancer InfoLink to note that 123 of the 439 men initially managed on active surveillance (28.0 percent) felt the need to undergo some form of deferred active treatment not because of any clear sign of disease progression but because of other reasons leading to a personal choice (anxiety, stress, the ?get it the heck outta there? syndrome?). If these men had continued on active surveillance, it is possible that the percentage of men with projected treatment-free survival at 10 years could have been as high as 90 percent or thereabouts. Is it possible that, as we see more data like these, that newly diagnosed men will be more acceptent of active surveillance as an initial management option?

It should also be noted that (as many prostate cancer advocates have pointed out in recent years) if one believes in screening of all men for risk of prostate cancer, this increases the responsibility of patient and physician to accept the idea that proactive monitoring or active surveillance (call it what you will) appears to be an extremely effective management option for almost half of all the patients at the time of initial diagnosis (although we still don?t know how many of those men may really need to be switched to a deferred form of active treatment at up to 25 years of follow-up).

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Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Treatment Tagged: | active surveillance, Management, risk, screening

Source: http://prostatecancerinfolink.net/2012/10/09/active-surveillance-deferred-treatment-and-outcomes-among-a-swedish-patient-cohort/

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