Drivers for Treatment after Active Surveillance: The Impact of Medical Specialty Following the Patient

Abstract

Active surveillance (AS) for prostate cancer has become an established management option for patients with low-risk prostate cancer. Randomized evidence from the PROTECT trial shows equivalent prostate-specific mortality between AS, radiation (RT), and surgery for prostate cancer detected via prostatic serum antigen (PSA). The main drivers for selection of treatment once a patient is placed on AS remains unclear. We describe the characteristics of our AS cohort and examine the reasons for proceeding with treatment, treatment modality selection, and assess impact of the medical specialist performing AS on patient decision making. Patients seen in consultation with very low-risk and low-risk prostate cancer were offered AS as one management option. A review of 2,545 patient charts with newly diagnosed prostate cancer from 2010-2016 was undertaken. Seven hundred ninety-four of those charts met institutional criteria for AS. One hundred sixty-seven of those meeting criteria chose to undergo AS within the radiation oncology department. Twenty-two of 167 opted to discontinue follow-up before their confirmatory studies, leaving 145 who underwent surveillance. Descriptive statistics were performed to characterize the patients in the cohort, proportion treated, reasons for treatment, and treatment choices. To compare the impact of the following-specialty on treatment choice, an additional 175 patients followed primarily by urology were added to the analysis. Two-sided Fisher’s exact test was used to compare proportions. Out of 145 patients, 138 (81.3%) had Gleason 3+3, 28 (17%) had Gleason 3+4 and 3 (1.8%) had Gleason 4+3. The majority (96.4%) were T1c and 112 (67%) were characterized as having NCCN very low risk with a mean PSA of 5.38ng/mL (± 2.38ng/mL). Ultimately 66 (45.5%) required or chose treatment. Of these, 36 (54.7%) were due to an increase in Gleason score or PSA rise, 14 (21%) electively decided against further AS, 6 (9%) for radiographic progression and 10 (15%) for other. The median time to initiate treatment was 3.8 years from diagnosis. Of the 175 patients followed primarily by urology, 59 (34%) received treatment. In total, 76 patients received RT, 36 patients received surgery, 12 received unknown, and 1 received primary hormone treatment due to PSA doubling-time. In comparing those followed by RT and those followed by surgery, patients were 15x more likely to receive RT if followed by a RT service than if followed by surgery (OR 15.4; p-value <.0001). In our cohort, men with low-risk prostate cancer and eligible for AS elected surveillance 21% of the time with slightly less than half of the cohort converting to treatment within 4 years. The most common reason for receiving treatment was either an increase in Gleason score or rise in PSA followed by patient anxiety regarding diagnosis. The choice of treatment is significantly impacted by the specialty performing the surveillance, which emphasizes the importance of the patient-physician relationship in men undergoing AS.