Why men abandon active surveillance for prostate cancer

Categories: Spring 2022
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There’s new research on active surveillance, and there’s still more to learn. © Sanford Radom, MD

Dr. Catalona’s multi-institutional collaborative research team’s SPORE project results were highlighted in Prostate Cancer Advisor, Oct. 2021. The key results, first reported in The Journal of Urology, were that men with high-volume Gleason Grade Group 1 tumors behaved similarly to those with higher-risk prostate cancers.

Among 6775 men who initially chose prostate cancer active surveillance or watchful waiting at 28 community clinics in the US, Canada, the Netherlands, and Australia during 1991-2018, 2260 men (33.4%) converted to treatment over a median of 6.7 years.  The reasons for conversion to active treatment included higher tumor grade (48.8%), tumor volume progression (7.2%), and PSA progression (8.5%), inclusive of men with overlapping factors; another 5% of men converted to treatment due to anxiety alone.

Compared with men who had Gleason Grade Group (GG) 1 tumor, men with GG2 and GG3-5 had significantly (57% and 77%) higher risks for conversion.  Every 5ng/mL increment in serum PSA was associated with an 18% higher risk for conversion.  Compared with men having a clinical-stage T1 tumor, those with clinical-stage T2, T3, or T4 tumor had a significantly 1.6-and 4.4-fold increased likelihood of converting to treatment, respectively.  As the number of biopsy cores with cancer increased from 1 or 2 to 3, 4, or more, the risk of conversion to active treatment increased significantly by 1.6-fold and 3.3-fold, respectively.

“High-volume (³4 cores) GG1 patients converted to treatment sooner than their low-volume (£3 cores) and intermediate-risk tumor counterparts, but at a similar interval to patients with high-risk tumors,” Dr. Catalona’s team reported.  “This finding warrants future investigation regarding tumor biology and counseling of men with high-volume GG1 disease.”

Every 5-year increase in age was significantly associated with a 4% lower risk of conversion indicating that younger men commonly switched to treatment.  A more recent year of diagnosis also predicted conversion to treatment, possibly reflecting that, in recent years, more patients with the higher-risk disease are initially adopting active surveillance as their initial management, and then sooner converting to active treatment.

Self-reported race coupled with genetic ancestry data did not significantly predict quicker conversion.  Longer-term research is required to determine the best candidates and criteria for active surveillance.

Cooley LF, et al. J Urol. 2021; 206: 1147-1156.

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