Two new reports — in combination with other published data — suggest that surveillance is a strategy that can be used safely and more widely for selected patients.
Overdiagnosis and overtreatment of localized prostate cancers with low risk for progression are increasingly recognized hazards of prostate-specific antigen (PSA) screening. Two new studies are relevant to this issue.
Researchers used a U.S. observational database to estimate the prevalence of "very-low-risk" prostate cancer among men with newly diagnosed disease. Men were considered to be at very-low risk if they met all of these criteria: PSA level <10 ng/mL at diagnosis, clinical stage T1 or T2a, PSA density <0.15, fewer than 1 in 3 biopsy cores positive, and absence of Gleason patterns 4 and 5. Of nearly 2000 patients, 310 (16%) met all criteria for very-low-risk disease, but only 9% of such men chose surveillance instead of treatment.
In another study, urologists at a single U.S. center described their experience with 40 patients whose prostate cancer was considered low risk (according to criteria similar to those listed above) and who elected active surveillance instead of immediate treatment. During follow-up (range, 1 to 14 years; median, 4 years), nine patients converted to active treatment — usually because of anxiety or rising PSA levels. The authors describe disease progression in only 1 of the 40 patients. No patient died from prostate cancer.
Comment: Neither of these cohorts is necessarily representative of patients seen in general practice: The database study included only patients who were evaluated for all five risk criteria, and all patients in the case series were managed by a single urologist. However, these reports — in combination with other published data — suggest that surveillance is a safe strategy that could be used more widely for men with very-low-risk prostate cancer.
— Allan S. Brett, MD
Published in Journal Watch General Medicine October 28, 2008
Barocas DA et al. What percentage of patients with newly diagnosed carcinoma of the prostate are candidates for surveillance? An analysis of the CaPSURE database. J Urol 2008 Oct; 180:1330.
Ercole B et al. Outcomes following active surveillance of men with localized prostate cancer diagnosed in the prostate specific antigen era. J Urol 2008 Oct; 180:1336.