Management Of Low-risk Prostate Cancer Research Articles

Choosing Wisely: The American Society for Radiation Oncology’s Top 5 list

PurposeTo highlight 5 interventions that patients should question, as part of the Choosing Wisely campaign. This initiative, led by the American Board of Internal Medicine Foundation, fosters conversations between physicians and patients about treatments and tests that may be overused, unnecessary, or potentially harmful. Methods and materialsPotential items were initially compiled using an online survey. They were then evaluated and refined by a work group representing the American Society for Radiation Oncology (ASTRO) Clinical Affairs and Quality, Health Policy, and Government Relations Councils. Literature reviews were carried out to support the recommendation and narrative, as well as to provide references for each item. A final list of 5 items was then selected by the ASTRO Board of Directors. ResultsASTRO’s 5 recommendations for the Choosing Wisely campaign are the following: (1) Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50 with early-stage invasive breast cancer without considering shorter treatment schedules; (2) don’t initiate management of low-risk prostate cancer without discussing active surveillance; (3) don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases; (4) don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry; and (5) don't routinely use intensity modulated radiation therapy to deliver whole-breast radiation therapy as part of breast conservation therapy. ConclusionsThe ASTRO list for the Choosing Wisely campaign highlights radiation oncology interventions that should be discussed between physicians and patients before treatment is initiated. These 5 items provide opportunities to offer higher quality and less costly care.

“Choosing Wisely”: The American Society for Radiation Oncology’s Top 5 List

Purpose/Objective(s)To highlight five interventions that patients should question, as part of the Choosing Wisely campaign. This initiative, led by the American Board of Internal Medicine Foundation, fosters conversations between physicians and patients about treatments and tests that may be overused, unnecessary, or potentially harmful.Materials/MethodsPotential items were initially compiled using an online survey. They were then evaluated and refined by a workgroup representing the American Society of Radiation Oncology (ASTRO) Clinical Affairs and Quality, Health Policy, and Government Relations councils. Literature reviews were carried out to support the recommendation, narrative and references for each item. The final list of five items was selected by the ASTRO Board of Directors.ResultsASTRO’s five recommendations for the Choosing Wisely campaign are: (1) Don’t initiate whole breast radiation therapy as a part of breast conservation therapy in women age ≥50 with early stage invasive breast cancer without considering shorter treatment schedules. (2) Do not initiate management of low-risk prostate cancer without discussing active surveillance. (3) Do not routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases. (4) Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry. (5) Don't routinely use intensity modulated radiation therapy (IMRT) to deliver whole breast radiation therapy as part of breast conservation therapy.ConclusionsThe ASTRO list for the Choosing Wisely campaign highlights radiation oncology interventions that physicians should discuss with their patients before treatment is initiated. These five items provide opportunities for offering higher quality care. Purpose/Objective(s)To highlight five interventions that patients should question, as part of the Choosing Wisely campaign. This initiative, led by the American Board of Internal Medicine Foundation, fosters conversations between physicians and patients about treatments and tests that may be overused, unnecessary, or potentially harmful. To highlight five interventions that patients should question, as part of the Choosing Wisely campaign. This initiative, led by the American Board of Internal Medicine Foundation, fosters conversations between physicians and patients about treatments and tests that may be overused, unnecessary, or potentially harmful. Materials/MethodsPotential items were initially compiled using an online survey. They were then evaluated and refined by a workgroup representing the American Society of Radiation Oncology (ASTRO) Clinical Affairs and Quality, Health Policy, and Government Relations councils. Literature reviews were carried out to support the recommendation, narrative and references for each item. The final list of five items was selected by the ASTRO Board of Directors. Potential items were initially compiled using an online survey. They were then evaluated and refined by a workgroup representing the American Society of Radiation Oncology (ASTRO) Clinical Affairs and Quality, Health Policy, and Government Relations councils. Literature reviews were carried out to support the recommendation, narrative and references for each item. The final list of five items was selected by the ASTRO Board of Directors. ResultsASTRO’s five recommendations for the Choosing Wisely campaign are: (1) Don’t initiate whole breast radiation therapy as a part of breast conservation therapy in women age ≥50 with early stage invasive breast cancer without considering shorter treatment schedules. (2) Do not initiate management of low-risk prostate cancer without discussing active surveillance. (3) Do not routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases. (4) Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry. (5) Don't routinely use intensity modulated radiation therapy (IMRT) to deliver whole breast radiation therapy as part of breast conservation therapy. ASTRO’s five recommendations for the Choosing Wisely campaign are: (1) Don’t initiate whole breast radiation therapy as a part of breast conservation therapy in women age ≥50 with early stage invasive breast cancer without considering shorter treatment schedules. (2) Do not initiate management of low-risk prostate cancer without discussing active surveillance. (3) Do not routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases. (4) Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry. (5) Don't routinely use intensity modulated radiation therapy (IMRT) to deliver whole breast radiation therapy as part of breast conservation therapy. ConclusionsThe ASTRO list for the Choosing Wisely campaign highlights radiation oncology interventions that physicians should discuss with their patients before treatment is initiated. These five items provide opportunities for offering higher quality care. The ASTRO list for the Choosing Wisely campaign highlights radiation oncology interventions that physicians should discuss with their patients before treatment is initiated. These five items provide opportunities for offering higher quality care.

Physician variation in management of low-risk prostate cancer: a population-based cohort study.

Up-front treatment of older men with low-risk prostate cancer can cause morbidity without clear survival benefit; however, most such patients receive treatment instead of observation. The impact of physicians on the management approach is uncertain. To determine the impact of physicians on the management of low-risk prostate cancer with up-front treatment vs observation. Retrospective cohort of men 66 years and older with low-risk prostate cancer diagnosed from 2006 through 2009. Patient and tumor characteristics were obtained from the Surveillance, Epidemiology, and End Results cancer registries. The diagnosing urologist, consulting radiation oncologist, cancer-directed therapy, and comorbid medical conditions were determined from linked Medicare claims. Physician characteristics were obtained from the American Medical Association Physician Masterfile. Mixed-effects models were used to evaluate management variation and factors associated with observation. No cancer-directed therapy within 12 months of diagnosis (observation). A total of 2145 urologists diagnosed low-risk prostate cancer in 12,068 men, of whom 80.1% received treatment and 19.9% were observed. The case-adjusted rate of observation varied widely across urologists, ranging from 4.5% to 64.2% of patients. The diagnosing urologist accounted for 16.1% of the variation in up-front treatment vs observation, whereas patient and tumor characteristics accounted for 7.9% of this variation. After adjustment for patient and tumor characteristics, urologists who treat non-low-risk prostate cancer (adjusted odds ratio [aOR], 0.71 [95% CI, 0.55-0.92]; P = .01) and graduated in earlier decades (P = .004) were less likely to manage low-risk disease with observation. Treated patients were more likely to undergo prostatectomy (aOR, 1.71 [95% CI, 1.45-2.01]; P < .001), cryotherapy (aOR, 28.2 [95% CI, 19.5-40.9]; P < .001), brachytherapy (aOR, 3.41 [95% CI, 2.96-3.93]; P < .001), or external-beam radiotherapy (aOR, 1.31 [95% CI, 1.08-1.58]; P = .005) if their urologist billed for that treatment. Case-adjusted rates of observation also varied across consulting radiation oncologists, ranging from 2.2% to 46.8% of patients. Rates of management of low-risk prostate cancer with observation varied widely across urologists and radiation oncologists. Patients whose diagnosis was made by urologists who treated prostate cancer were more likely to receive up-front treatment and, when treated, more likely to receive a treatment that their urologist performed. Public reporting of physicians' cancer management profiles would enable informed selection of physicians to diagnose and manage prostate cancer.

Contemporary Use of Initial Active Surveillance Among Men in Michigan with Low-risk Prostate Cancer

BackgroundActive surveillance (AS) has been proposed as an effective strategy to reduce overtreatment among men with lower risk prostate cancers. However, historical rates of initial surveillance are low (4–20%), and little is known about its application among community-based urology practices. ObjectiveTo describe contemporary utilization of AS among a population-based sample of men with low-risk prostate cancer. Design, setting, and participantsWe performed a prospective cohort study of men with low-risk prostate cancer managed by urologists participating in the Michigan Urological Surgery Improvement Collaborative (MUSIC). Outcome measurements and statistical analysisThe principal outcome was receipt of AS as initial management for low-risk prostate cancer including the frequency of follow-up prostate-specific antigen (PSA) testing, prostate biopsy, and local therapy. We examined variation in the use of surveillance according to patient characteristics and across MUSIC practices. Finally, we used claims data to validate treatment classification in the MUSIC registry. Results and limitationsWe identified 682 low-risk patients from 17 MUSIC practices. Overall, 49% of men underwent initial AS. Use of initial surveillance varied widely across practices (27–80%; p=0.005), even after accounting for differences in patient characteristics. Among men undergoing initial surveillance with at least 12 mo of follow-up, PSA testing was common (85%), whereas repeat biopsy was performed in only one-third of patients. There was excellent agreement between treatment assignments in the MUSIC registry and claims data (κ=0.93). Limitations include unknown treatment for 8% of men with low-risk cancer. ConclusionsHalf of men in Michigan with low-risk prostate cancer receive initial AS. Because this proportion is much higher than reported previously, our findings suggest growing acceptance of this strategy for reducing overtreatment. Patient summaryWe examined the use of initial active surveillance for the management of men with low-risk prostate cancer across the state of Michigan. We found that initial surveillance is used much more commonly than previously reported, but the likelihood of a patient being placed on surveillance depends strongly on where he is treated.

Concurrent management of low-risk prostate cancer and localized small lymphocytic lymphoma in a man without competing risks despite advanced age

Concurrent management of low-risk prostate cancer and localized small lymphocytic lymphoma in a man without competing risks despite advanced age

ASTRO 2013

ASTRO 2013

Overtreatment of low-risk prostate cancer in the United States: Incidence, cost, complications, and implications for the screening debate.

161 Background: The National Comprehensive Cancer Network (NCCN) recommends active surveillance as the sole option for men with low-risk prostate cancer (LRPC) and a life expectancy &lt;10 years. We sought to describe the incidence, risk factors, cost, and morbidity related to overtreatment of LRPC within the United States. Methods: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare Program to identify 11,744 men ≥66 years with LRPC diagnosed from 2004-2007. Expected survival was estimated using the 2007 Social Security Life Table and was increased and decreased by 50% in men in the upper and lower quartiles of comorbidity, respectively, as specified by the NCCN. Overtreatment was definitive treatment in men with LRPC and life expectancy &lt;10 years. Costs were the amount paid by Medicare in the year following minus the year prior to diagnosis. Toxicities were defined as relevant Medicare diagnoses or interventions. Results: Of 3001 men with LRPC and a life expectancy &lt;10 years, 2011 (67%) were treated definitively. On multivariable logistic regression, men overtreated for prostate cancer were more likely to be younger (p&lt;.001), white (vs black, OR 1.44, 95% CI 1.03-2.02, p=.03), married (OR 1.30, 95% CI 1.05-1.61, p=.02), urban (trend, OR 1.40, 95% CI 0.98-2.00, p=.06), have higher Elixhauser comorbidity (p&lt;.001), and have a higher clinical stage (T2 vs T1, OR 1.57, 95% CI 1.19-2.07, p=.001) and prostate-specific antigen level (OR 1.02, 95% CI 1.02-1.02, p&lt;.001). Relative to expectant management, the mean added cost per definitive treatment was $15,308. When extrapolated nationally the cumulative net cost of overtreatment in men ≥66 years is $32 million per annum. Long-term urinary, erectile, and bowel toxicity occurred in 59.2% and 50.0%, 47.9% and 19.7%, and 7.1% and 17.8% of prostatectomy and radiation patients, respectively. Conclusions: Overtreatment of prostate cancer is partially driven by sociodemographic factors and occurs in a high percentage of men with LRPC and limited life expectancy, with marked impact on patient quality of life and health care costs. Efforts to enhance appropriate management of LRPC would reduce the harms associated with screening.

Divorcing Diagnosis From Treatment: Contemporary Management of Low-Risk Prostate Cancer

Today, the majority of men with newly diagnosed prostate cancer will present with low-risk features of the disease. Because prostate cancer often takes an insidious course, it is debated whether the majority of these men require radical treatment and the accompanying derangement of quality of life domains imposed by surgery, radiation, and hormonal therapy. Investigators have identified various selection criteria for "insignificant disease," or that which can be monitored for disease progression while safely delaying radical treatment. In addition to the ideal definition of low risk, a lack of randomized trials comparing the various options for treatment in this group of men poses a great challenge for urologists. Early outcomes from active surveillance cohorts support its use in carefully selected men with low-risk disease features, but frequent monitoring is required. Patient selection and disease monitoring methods will require refinement that will likely be accomplished through the increased use of biomarkers and specialized imaging techniques.

Delayed radical prostatectomy for intermediate‐risk prostate cancer is associated with biochemical recurrence: Possible implications for active surveillance from the SEARCH database

Active surveillance (AS) is increasingly accepted as appropriate management for low-risk prostate cancer (PC) patients. It is unknown whether delaying radical prostatectomy (RP) is associated with increased risk of biochemical recurrence (BCR) for men with intermediate-risk PC. We performed a retrospective analysis of 1,561 low and intermediate-risk men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database treated with RP between 1988 and 2011. Patients were stratified by interval between diagnosis and RP (≤ 3, 3-6, 6-9, or >9 months) and by risk using the D'Amico classification. Cox proportional hazard models were used to analyze BCR. Logistic regression was used to analyze positive surgical margins (PSM), extracapsular extension (ECE), and pathologic upgrading. Overall, 813 (52%) men were low-risk, and 748 (48%) intermediate-risk. Median follow-up among men without recurrence was 52.9 months, during which 437 men (38.9%) recurred. For low-risk men, RP delays were unrelated to BCR, ECE, PSM, or upgrading (all P > 0.05). For intermediate-risk men, however, delays >9 months were significantly related to BCR (HR: 2.10, P = 0.01) and PSM (OR: 4.08, P < 0.01). Delays >9 months were associated with BCR in subsets of intermediate-risk men with biopsy Gleason score ≤ 3 + 4 (HR: 2.51, P < 0.01), PSA ≤ 6 (HR: 2.82, P = 0.06), and low tumor volume (HR: 2.59, P = 0.06). For low-risk men, delayed RP did not significantly affect outcome. For men with intermediate-risk disease, delays >9 months predicted greater BCR and PSM risk. If confirmed in future studies, this suggests delayed RP for intermediate-risk PC may compromise outcomes.

The role of targeted focal therapy in the management of low-risk prostate cancer: update on current challenges.

Prostate cancer is one of the most prevalent cancers among men in the United States, second only to nonmelanomatous skin cancer. Since prostate-specific antigen (PSA) testing came into widespread use in the late 1980s, there has been a sharp increase in annual prostate cancer incidence. Cancer-specific mortality, though, is relatively low. The majority of these cancers will not progress to mortal disease, yet most men who are diagnosed opt for treatment as opposed to observation or active surveillance (AS). These men are thus burdened with the morbidities associated with aggressive treatments, commonly incontinence and erectile dysfunction, without receiving a mortality benefit. It is therefore necessary to both continue investigating outcomes associated with AS and to develop less invasive techniques for those who desire treatment but without the significant potential for quality-of-life side effects seen with aggressive modalities. The goals of this paper are to discuss the problems of overdiagnosis and overtreatment since the advent of PSA screening as well as the potential for targeted focal therapy (TFT) to bridge the gap between AS and definitive therapies. Furthermore, patient selection criteria for TFT, costs, side effects, and brachytherapy template-guided three-dimensional mapping biopsies (3DMB) for tumor localization will also be explored.

Personalized management in low-risk prostate cancer: the role of biomarkers.

Current criteria to predict low-risk prostate cancer (PCa) are still subject to discussion as a substantial number of PCa patients who progress to a more aggressive disease seem to be missed, using these criteria. The main challenge in PCa diagnosis, therefore, is to distinguish patients with low-risk PCa who will show slow progression of disease from patients at risk for progression to a more aggressive cancer. The current discovered biomarkers could potentially guide in this management and improve detection, staging, and prognosis. This paper provides an overview of the current available serum-, urine-, and tissue-based biomarkers in PCa and evaluates the clinical usefulness of these biomarkers in the detection and management of low-risk PCa.

Focal External Beam Radiation Therapy in Management of Low-Risk Prostate Cancer: A Radiobiological Analysis

To demonstrate via radiobiological modeling that a high radiation dose to MR-detectable intraprostatic lesions (IL) combined with a reduced dose to the remaining prostate gland maintains a high bNED control rate while significantly diminishing the likelihood of late tissue complications.

Focal therapy in prostate cancer: modalities, findings and future considerations

Focal therapy is emerging as an alternative to active surveillance for the management of low-risk prostate cancer in carefully selected patients. The aim of focal therapy is long-term cancer control without the associated morbidity that plagues all radical therapies. Different energy modalities have been used to focally ablate cancer tissue, and available techniques include cryotherapy, laser ablation, high-intensity focused ultrasound and photodynamic therapy. The majority of evidence for focal therapy has come from case series and small phase I trials, and larger cohort studies with longer follow-up are only now being commenced. More data from large trials on the safety and efficacy of focal therapy are therefore required before this approach can be recommended in men with prostate cancer; in particular, studies must confirm that no viable cells remain in the region of ablation. Focal therapy might eventually prove to be a 'middle ground' between active surveillance and radical treatment, combining minimal morbidity with cancer control and the potential for re-treatment.

Radikal Umdenken!

Prostate-specific antigen screening leads to the detection of prostate cancers that never would have become symptomatic and thereby also leads to potential overtreatment. The concept of active surveillance (AS) addresses this situation by deferring radical treatment of clinically localised prostate cancer as long as no relevant progression is diagnosed. The available evidence suggests that AS is a generally safe treatment option for low-risk prostate cancer. In practice, however, it still does not seem to be accepted for economic and historical reasons. Because radical treatment may highly affect the patient’s quality of life, AS should become a more common option in the management of low-risk prostate cancer.

Evidence-Based Medicine, Conscience-Based Medicine, and the Management of Low-Risk Prostate Cancer

Evidence-Based Medicine, Conscience-Based Medicine, and the Management of Low-Risk Prostate Cancer

Factors Influencing Men Undertaking Active Surveillance for the Management of Low-Risk Prostate Cancer

To identify and describe decision-making influences on men who decide to manage their low-risk prostate cancer with active surveillance. Qualitative, semistructured interview. The Prostate Centre at Vancouver General Hospital in Canada. 25 patients diagnosed with low-risk prostate cancer and on active surveillance. An interpretative, descriptive, qualitative design. Factors that influenced men's decisions to take up active surveillance. The specialists' description of the prostate cancer was the most influential factor on men choosing active surveillance. Patients did not consider their prostate cancer to be life threatening and, in general, were relieved that no treatment was required. Avoiding treatment-related suffering and physical dysfunction and side effects such as impotence and incontinence was cited as the major reason to delay treatment. Few men actively sought treatment or health-promotion information following their treatment decision. Female partners played a supportive role in the decision. The need for active treatment if the cancer progressed was acknowledged. Patients were hopeful that new treatments would be available when and if they needed them. Being older and having comorbidities did not preclude the desire for future active treatment. Patients carried on with their lives as usual and did not report having any major distress related to being on active surveillance. The study findings indicate that men are strongly influenced by the treating specialist in taking up active surveillance and planning future active treatments. As such, most men relied on their specialists' recommendation and did not perceive the need for any adjunct therapy or support until the cancer required active treatment. Oncology nurses should work collaborative-ly with specialists to ensure that men receive the information they need to make informed treatment decisions.

Management of low-risk prostate cancer

Management of low-risk prostate cancer

Does radical treatment have a role in the management of low-risk prostate cancer? The place for brachytherapy and external beam radiotherapy

A number of forms of radiation therapy are now commonly used for the treatment of low-risk prostate cancer (LRPCa). The tumour control rates are typically excellent, and the risk of death from prostate cancer very low regardless of the treatment modality. This is despite there being a paucity of prospective evidence with which to guide the radiation oncologist in this particular disease subtype. Much of the decision-making will fall back to evidence extrapolated from much more advanced or high-grade malignancy, while our current understanding of comorbidities poorly illuminates the initial question of whether or not the patient requires radical treatment at all. The number of variables in the treatment selection algorithm continues to increase, with a virtually unending array of treatment options when one combines the available variations in radiation modality, technique, dose and dose fractionation. All treatment is associated with a risk of toxicity, and there are substantial differences in the toxicity seen between the modalities. A number are strongly associated with pre-existing conditions and can be seen as relative contraindications to either a specific radiation modality, or any treatment in general. This article aims to review data regarding LRPCa and radiotherapy outcomes, and highlight the potential challenges to improve this data in a planned manner.