Observation Is Safe, Cost-saving Option for Patients with Low-risk Prostate Cancer
Many men with low-risk, localized prostate cancers can safely choose active surveillance or watchful waiting instead of undergoing immediate treatment and have better quality of life while reducing health-care costs, according to a study by researchers at Dana-Farber Cancer Institute and Massachusetts General Hospital.
Writing in the June 18 issue of the Annals of Internal Medicine, the authors said their statistical models showed that “observation is a reasonable and, in some situations, cost-saving alternative to initial treatment” for the estimated 70% of men whose cancer is classified as low-risk at diagnosis.
Observation Underused for Men with Low-risk Disease
The researchers, led by Julia Hayes, MD, a medical oncologist in the Lank Center for Genitourinary Oncology at Dana-Farber, said their findings support observation as a reasonable and underused option for men with low-risk disease.
“About 70% of men in this country have low-risk prostate cancer, and it’s estimated that 60% of them are treated unnecessarily” with various forms of radiation or having the disease removed with radical prostatectomy surgery, said Dr. Hayes, who is also a senior scientist at Massachusetts General Hospital’s Institute for Technology Assessment. The PIVOT clinical trial reported that such men had about the same small risk of death over a 12-year period whether they underwent radical prostatectomy or simply observation.
In active surveillance, patients undergo blood tests for prostate-specific antigen every 3 months, rectal examinations every 6 months, and a prostate gland biopsy at 1 year and then every 3 years. If the tests find the cancer is more aggressive than originally thought, the patients begin treatment aimed at curing the disease. “This approach could also be described as deferred treatment,” said Dr. Hayes.
A patient who chooses watchful waiting is observed without intensive monitoring and is given palliative treatment when the cancer becomes symptomatic.
Treatments for low-risk prostate cancer include radical prostatectomy, intensity-modulated radiation therapy (IMRT), or brachytherapy.
Study Details
Dr. Hayes and her coauthors created mathematical models to construct a variety of scenarios, focusing on men aged 65 or 75 years at diagnosis, and including estimated costs associated with treatment and different forms of observation.
The investigators calculated the quality-adjusted life expectancy for the different strategies. The researchers also estimated the lifetime costs of each strategy, which ranged from $18,302 for watchful waiting for men aged 75 to $48,699 for a 65-year-old patient treated with IMRT therapy.
The study found that observation was more effective and in some cases less costly than initial treatment for low-risk prostate cancers. Watchful waiting yielded 11 months additional quality-adjusted life expectancy over brachytherapy, the most effective treatment, and 13 months additional quality-adjusted life expectancy over radical prostatectomy, the least effective treatment.
Safe Alternatives to Initial Treatment
Dr. Hayes acknowledged that the study made assumptions based on limited research data on these issues. Nevertheless, “it appears that active surveillance and watchful waiting are safe alternatives to initial treatment for prostate cancer based on these assumptions. But it’s important to emphasize that these decisions are very much a matter of individual choice.”
Study coauthor Philip Kantoff, MD, Director of the Lank Center for Genitourinary Oncology at Dana-Farber and Professor of Medicine at Harvard Medical School, commented, “This study delineates the cost benefit of active surveillance as well as watchful waiting, the less aggressive assessment strategy.
“A previous study by Dr. Hayes and colleagues demonstrated that active surveillance is a reasonable option for men with low-risk disease and associated with a better quality of life,” Dr. Kantoff added. “As nontreatment becomes a more accepted option for these patients, selecting those who require less aggressive assessment including biopsy will become important.”
The research was supported by National Cancer Institute grant CA92203-08, Department of Defense grant W81XWH-09-0512, and a grant from the Prostate Cancer Foundation.
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®.
