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Most Men With Low-Risk Prostate Tumors Now Forgoing Treatment

photo of prostate cancer anatomy

May 17, 2022 -- The number of men with prostate cancer who chose to have their disease monitored rather than treated doubled nationally between 2014 and 2021, according to experts who say the dramatic increase shows a growing understanding that low-grade prostate tumors can be safely watched for years without treatment.

Roughly 60% of men eligible for what’s known as active surveillance chose that approach in 2021, up from 27% in 2014 and less than 10% in 2010, according to Matthew Cooperberg, MD, MPH, of University of California San Francisco. He presented at the the American Urological Association (annual meeting this month.

Cooperberg said the rise in surveillance rates in the United States is likely thanks to new guidelines and research that support the approach, which calls for regular assessments of low-risk tumors but no surgery, radiation, or other therapies. In Canada and parts of Europe, about 80%-90% of men who are eligible for active surveillance choose that approach.

Earlier this month, the American Urological Association and the American Society for Radiation Oncology released the strongest guidelines to date supporting surveillance for low-risk patients, and, for the first time, for some patients with intermediate-risk prostate cancer.

In 2012, the U.S. Preventative Services Task Force recommended against prostate-specific antigen testing, concluding that the benefits of the test did not outweigh the risks, such as overdiagnosis and overtreatment of low-risk prostate cancer.

Urologists blamed the task force policy for a decline in PSA screening and an uptick in the diagnosis of advanced prostate cancer.

Cooperberg said the shift served as "a bit of a wake-up call for at least a segment of the urology community that if we didn't fix the overtreatment problem, we would never retake the chunks of the conversation about screening and early detection."

Laurence Klotz, MD, the University of Toronto researcher who named and helped develop active surveillance 30 years ago, said other factors also help to explain the growing interest in as the technique. These include an increasing agreement among experts on the value of the strategy, growing public awareness of its benefits, the efforts of advocacy groups, and the arrival of better imaging and biomarkers that help further refine risk.

"We're shrinking the gray zone," Klotz said. "Remaining resistance to [active surveillance] is due to legitimate concerns about missing significant cancer and losing a patient to metastatic disease, and perhaps financial drivers, particularly with less invasive technologies like radiation and focal therapy."

In 2014, surgery to remove part or all of the prostate was the leading treatment in the low-risk population, with 29.7% of these patients overall opting for surgery, slightly more than those who had radiation treatment (28.2%) and those who chose active surveillance (26.5%).

Aiming Higher

William Catalona, MD, from Northwestern University, said the American Urological Association’s Prostate Cancer Active Surveillance Project’s goal is to have 80% of patients with low-risk prostate cancer to use active surveillance. Catalona, an early critic of as the technique, called that figure "optimal and realistic" and said it should happen "as soon as possible."

Catalona said the 80% benchmark matches rates of surveillance among Veterans Affairs patients.

However, Klotz said the American culture of treatment, which is driven at least in part by financial incentives for doctors, may make it difficult to reach that goal.

Cooperberg said financial incentives are real.

"I think it's a small minority of docs that are heavily driven by the financial incentive, but it certainly exists," he said. “When you look at the extreme variation of active surveillance rates, there is no question that factors like reimbursement are going to play a role."