Risk-Appropriate Therapies Now Commonplace in Prostate Cancer Treatment
After decades of overtreatment for low-risk prostate cancer and inadequate management of its more aggressive forms, patients are now more likely to receive medical care matched to level of risk, according to a study by researchers at the University of California, San Francisco (UCSF). Cooperberg and Carroll published their findings in JAMA.
Study Findings
In the first study to document updated treatment trends, researchers found that from 2010 to 2013, 40% of men with low-risk prostate cancer opted for active surveillance, in which the disease is monitored closely with blood tests, imaging studies, and biopsies. Treatment is deferred unless these tests show evidence of progression.
In contrast, less than 10% overall of patients with low-risk prostate cancer pursued active surveillance from 1990 through 2009. Rates for radiation therapy for this low-risk group have also slipped since 1995.
Meanwhile, men with higher-risk tumors are more likely to undergo surgical removal of the prostate and/or radiation, localized treatments that are more effective than androgen-deprivation therapy alone. In men with intermediate-risk disease, 9.7% were treated with this therapy in 1990–1994, vs 3.8% in 2010–2013. Among those with high-risk disease, 30% and 24% of patients, respectively, underwent this treatment in these same periods.
“We expected to see a rise in surveillance rates, but were surprised by the steepness of the trajectory. It shows a major shift toward appropriate, risk-adapted management of the disease,” said Matthew Cooperberg, MD, MPH, Associate Professor in the Departments of Urology and Epidemiology & Biostatistics at UCSF, and Helen Diller Family Chair in Urology at the UCSF Helen Diller Family Comprehensive Cancer Center.
“Active surveillance has been a mainstay for years at a few other academic centers but is increasingly broadly endorsed in recent years. Our study follows on from numerous others that have documented consistent overtreatment of low-risk cancer that would never cause any symptoms or loss of life expectancy had it never been diagnosed. At the same time, we're seeing more aggressive management of higher-risk disease, which will lead to better outcomes,” he said.
Dr. Cooperberg, along with Peter Carroll, MD, MPH, analyzed data of close to 10,500 prostate cancer patients from 45 urology practices nationwide, collected in UCSF's Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry. In patients aged 75 or older, they observed that the rate of active surveillance had soared from 22% in 2000–2004 to 76% in 2010–2013. However, the incidence of surgery had stagnated in this high-risk group.
Low-risk patients seeking treatment may be younger and motivated by anxiety, perhaps related to a family history of cancer or obstructive urinary symptoms, said Dr. Carroll, Professor and Chair of the Department of Urology at UCSF.
Appropriate Screening for Appropriate Treatment
The authors said that they hope the results of the study will generate renewed discussion on the merits of prostate-specific antigen (PSA) screening.
“Because of concerns about overtreatment, many primary care physicians no longer support PSA testing. This means that low-risk tumors, which do not require treatment, go unnoticed,” said Dr. Carroll. “But it also means that high-risk tumors that are potentially lethal without early identification and intervention may go unnoticed, too. We hope the results of this study will lead toward a smarter screening and treatment paradigm, which is what many men need and deserve.”
Dr. Cooperberg is the corresponding author for the JAMA article.
Dr. Cooperberg has received consulting fees from Myriad Genetics, Astellas, and Bayer. Dr. Carroll is receiving grants and has received personal fees from Genomic Health.
CaPSURE was supported by funding from TAP Pharmaceutical Products until 2007. It is currently funded by the U.S. Department of Defense and the UCSF Department of Urology. The UCSF Department of Urology is receiving grants from Myriad Genetics, Genomic Health, and GenomeDx.
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®.
