PerspectiveIn the Journals

Management of localized prostate cancer has improved in community-based practices

Show Citation

July 7, 2015

The use of active surveillance and watchful waiting for patients with low-risk prostate cancer significantly increased since 2010 in community-based practices, according to study findings.

Further, high-risk disease was treated more frequently with curative local treatment rather than androgen deprivation therapy alone, results also showed.

Matthew R. Cooperberg, MD, MPH, associate professor of urology epidemiology and biostatistics and the Helen Diller Family Chair in urology and Peter R. Carroll, MD, MPH, professor and chair of the department of urology at the University of California, San Francisco, conducted a study to examine trends in the management of localized prostate cancer within community-based practices.

Matthew R. Cooperberg, MD, MPH

Matthew R. Cooperberg

“A number of studies over the years, from our group and others, have documented consistent overtreatment of low-risk prostate cancer — that is, use of surgery, radiation and other treatments for tumors that would never cause any symptoms or loss of life expectancy had they never been diagnosed,” Cooperberg told HemOnc Today.Active surveillance has been a mainstay of management for years only in a few selected academic centers, but has been increasingly broadly endorsed in recent years. No studies have yet documented updated treatment trends at the national level in the current decade, and this was our goal.”

Researchers evaluated data from 10,472 men (mean age, 65.7 years; 87% white) in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a national registry that has accrued data on men with prostate cancer diagnosed at one of 45 urology practices in the United States since 1995. All but three of the practices are community based. Men were enrolled retrospectively and prospectively before 1998, but only prospectively after 1998.

The men included had stage cT3aNoMo or lower tumors managed with prostatectomy, radiation, ADT alone or active surveillance/watchful waiting between 1990 and 2013. 

The median Cancer of the Prostate Risk Assessment (CAPRA) score in the population was 2 (range, 1-4).

The use of surveillance remained low for those with low-risk disease — or a CAPRA score of 0 to 2 — between 1990 (6.7%; 95% CI, 5.8-7.6) and 2009 (14.3%; 95% CI, 10.3-18.3).

However, from 2010 through 2013, surveillance use among men with low-risk disease increased significantly to 40.4% (95% CI, 34.9-45.9; P ˂ .001 for trend).

“This is excellent news, because it suggests a major shift toward more appropriate, risk-adapted management of both low- and high-risk disease,” Cooperberg said. “I’m not sure we know the ideal rate of surveillance for low-risk disease — some men with low-risk disease may choose immediate treatment for a variety of reasons, eg, obstructive urinary symptoms and poor sexual function at baseline, severe anxiety related to family history, etc.”

Some centers, like UCSF, use surveillance for a majority of men with low-risk disease, Cooperberg added.

“I’m not sure there’s too much of a danger of the pendulum over-swinging in this regard,” he said. “Ultimately, the number of men who will die of prostate cancer because they chose active surveillance cannot be zero by definition, but it is a very low number — far lower by most estimations than the number of those harmed by avoidable surgery, radiation, etc.”

Further, although the use of ADT increased steadily for intermediate-risk (9.7%; 95% CI, 7-12.3) and high-risk tumors (29.8%; 95% CI 23.3-36.4) between 1990 and 2009, it decreased to 3.8% (95% CI, 1.2-6.4) for intermediate-risk tumors and 24% (95% CI, 14.1-33.9) for high-risk tumors by 2013.

Among men aged 75 years or older, the rate of surveillance use was 54.1% (95% CI, 37.2-70.9) from 1990 and 1994 and then dropped to 21.9% (95% CI, 17.4-26.4) from 2000 through 2004. However, the surveillance rate then increased to 76.2% (95% CI, 56.3-96.1) from 2010 through 2013.

In this subset of patients, there was an increase in the use of surgery for those with low-risk prostate cancer (9.5%; 95% CI, –4.1 to 23.2) and intermediate-risk prostate cancer (15%; 95% CI, –2.1to 32.1); however, there was not an increase in the use of surgery in the high-risk portion of this population, for whom ADT accounted for 66.7% (95% CI, 39.6-93.7) of treatment.

Surveillance rates based on individual urology practices ranged from 8.3% to 63.6% (median, 36%; range 12.7-54.1).

Cooperberg and Carroll wrote that the major limitation of these data is that CaPSURE is not randomly populated; however, this may be overcome by the fact that the participating urology practices having broad and varied characteristics with patients similar demographically to those in the SEER database.

“We expected to see a rise in surveillance rates, but were surprised by the steepness of the trajectory,” Cooperberg said. “This really does represent a paradigm change, and yes, it’s faster than the typical pace of medical evolution. The factors converging to drive this rapid change include increasingly clear endorsement of surveillance by a variety of practice guidelines including statements by national urology and radiation oncology organizations, growing data regarding the safety of the approach, and, probably, an awareness by more urologists that changes in management are necessary from the critical perspective of future PSA screening policy.” – by Anthony SanFilippo

For more information:

Matthew R. Cooperberg, MD, MPH, can be reached at the University of California, San Francisco, 1600 Divisadero St., San Francisco, CA 94115; email:

Disclosure: Cooperberg reports research grants from Genomic Health, GenomeDx and Myriad Genetics and personal fees from Astellas, Bayer, Denendron and Myriad.

itj+ Infographic

itj+ Perspective

Eric A. Klein

Eric A. Klein

It is now well established that repeated screening with PSA in men aged older than 50 years overdetects nonlethal prostate cancer, resulting in many men undergoing unneeded and morbid therapy. In recognition of this problem, the urologic community has committed great effort to designing and optimizing active surveillance protocols, wherein patients with very low- or low-risk disease as characterized by National Comprehensive Cancer Network guidelines are periodically monitored after initial biopsy and treated only if there is evidence of cancer progression. The safety of this approach has recently been demonstrated by two long-term studies that demonstrate a very low risk for metastasis or death in men managed in this fashion.
Despite these convincing data, active surveillance has remained underutilized nationally. A recent study using data from the National Cancer Data Base estimated that only 12% of patients at lowest risk for progression enter a surveillance protocol, with some geographic regions demonstrating less than 10% use of this strategy. Underuse of surveillance has many root causes, including patient and family anxiety about any diagnosis of cancer, a reimbursement and training system that rewards intervention, legal concerns over missing tumor progression, uncertainty about how often current biopsy schemes underdetect biologically significant disease, and what represents true progression on subsequent biopsy.
Happily — as Cooperberg and colleagues demonstrate — in enlightened practices, this situation is starting to change. Among CaPSURE sites, 40% of patients at lowest risk for progression, and 70% of those aged 75 or older, were managed by surveillance between 2010 and 2103. Similar progress also has been reported by other groups, notably the Michigan Urological Surgery Improvement Collaborative, which recently reported a 49% use of surveillance among participating urology practices.
A number of new tools adjunctive to biopsy are now on the market — including multiparametric MRI and genomic profiling — and early data suggest that their use improves patient selection and monitoring and increases the use of surveillance.
We have come full circle from the early PSA era, where the goal was to find and treat every prostate cancer. In 2016, the old goals should be supplanted by the goals of treating only those cancers that have lethal potential, and managing all others by active surveillance.
Badani KK, et al. BJU Int. 2015;doi:10.1111/bju.12789.
Klotz L, et al. J Clin Oncol. 2014;doi:10.1200/JCO.2014.55.1192.
Maurice MJ, et al. JAMA Intern Med. 2015;doi:10.1001/jamainternmed.2015.2835.
Tosoian JJ, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2015.62.5764.

Eric A. Klein, MD
Cleveland Clinic

Disclosure: Klein reports no relevant financial disclosures.