Study Finds a Quarter of Men Drop Out of Prostate Cancer Monitoring, Casting Doubt on Safety of Active Surveillance
Noncompliance appears to be a major challenge for active surveillance, according to the results of long-term follow-up of patients with prostate cancer presented at the European Association of Urology 29th Annual Congress in Stockholm. Over a quarter of men dropped out of the active surveillance program during the course of the 13-year study.
Prostate cancer is the most common cancer in men, with a European incidence rate of 214 cases per 1,000 men, outnumbering lung and colorectal cancer. Research shows that with advancing age, most men are likely to have a cancer of the prostate, although for many the cancer will be so slow-growing that it does not create a real problem. Recently there has been significant visibility given to the risk of prostate cancer overdiagnosis.
Given that treatment for prostate cancer involves either radiotherapy or major surgery, which can cause significant side effects, such as incontinence and impotence, there has been an increasing tendency to keep low-risk men under active surveillance. However, there have been very few studies showing how this surveillance works in real life.
Study Details
This prospective, single-arm study included 157 patients from a nonacademic urologic institution who were followed over a period of 13 years’ active surveillance. If patients failed to appear, they were contacted at least two times by mail explaining the importance of follow-up.
After 13-years follow-up, 28% of all patients experienced progression and required definitive treatment. Almost all of these men were cured from cancer, with an overall survival rate of 94%, cancer-specific survival of 99%, and progression-free survival of 98%. However, it was also found that about 27% of all patients did not show up to the recommended appointments, the key element of active surveillance. These men did not reply to follow-up letters requesting ongoing check-up, thus dropping out of the active surveillance system.
The ‘Patient Factor’
Lead researcher Lukas Hefermehl, MD, of Kantonsspital Baden, noted that despite the small sample size of this study, it is nevertheless “one of the best ‘real-world’ samples we have with long-term data.”
“I strongly believe that active surveillance is a good option for men who follow the recommended controls. But from our results it looks like there must be a significant number of men lost to follow-up who will eventually develop of a progressive disease; many of these men may even eventually die of prostate cancer. As urologists, we still remain responsible for these patients,” he said.
The group also found that just 3 months after the initial diagnosis, 30 men (19%) refused a mandatory confirmation biopsy that could have ruled out a wrong interpretation of the first biopsy.
Dr. Hefermehl continued, “We don't know exactly what the reasons are. It may be that once the patient was told that this cancer is probably ‘not immediately threatening,’ he might downplay the importance of another test. On the other hand some men might have real concerns about the risk of there being a more severe cancer. Or it may have to do with the risk of incontinence or impotence after treatment, the idea of having cancer, a sense that nothing will really happen to them—or it may be due to another reason which we just don't know about.
“But the fact is that overall these findings leave us with a practical and ethical dilemma; we often recommend that men go onto an active surveillance program, but these results indicate that more than a quarter of men will disappear from the system. We strongly believe that this ‘patient factor’ must be taken into account for future active surveillance protocols.”
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
