Hundreds of men in the UK are opting to delay aggressive treatment for prostate cancer in favour of being closely monitored, according to the first figures on the groundbreaking new care approach published in the British Journal of Urology.
Dr Chris Parker from The Institute of Cancer Research (ICR) and The Royal Marsden pioneered the technique of Active Surveillance, which since 2008 has been recommended by the National Institute for Health and Clinical Excellence (NICE) as an option for patients with low-risk, localised prostate cancer.
Active Surveillance ensures that men only receive treatment if they genuinely need it. While some prostate cancers are aggressive, others never require treatment. There is currently no test to distinguish between life-threatening prostate cancer and relatively benign cancer, so under Active Surveillance men are regularly monitored by biopsy and testing levels of prostate specific antigen (PSA) in the blood to see if their cancer progresses. The method allows some men to avoid surgery and radiotherapy, which can carry significant side-effects including impotence for half of men and incontinence for one in 20.
In a study funded by the ICR, Cancer Research UK and the NCRI South of England Prostate Cancer Collaborative, Dr Parker reports that almost four in 10 men diagnosed with low-risk prostate cancer in the UK chose active surveillance in 2006.
“This is the first study to examine the treatment choices of men diagnosed with low-risk prostate cancer in the UK, and it demonstrates a major increase over time in the use of Active Surveillance,” Dr Parker says. “This growth in Active Surveillance use represents a significant shift of clinical practice in Britain and contrasts sharply with the US, where about 95 per cent of low-risk patients have radical treatment.”
Dr Parker analysed 43,322 cases of localised prostate cancer recorded between 2002 and 2006 on the British Association of Urological Surgeons (BAUS) Cancer Registry, a database of patients diagnosed with urological cancer at 150 UK institutions.
About 20 per cent of these men met the criteria for low-risk disease, based on PSA level, physical examination and biopsy results. These 8,800 men – who were more likely to be younger and come from more affluent areas, compared to men diagnosed with intermediate and high-risk disease - were candidates for Active Surveillance, although it is not clear if they were all offered this option.
From 2002 until 2006, the proportion of these men who opted for Active Surveillance increased from zero per cent to 39 per cent. Consequently, the proportion of patients opting for surgery and radiotherapy declined over the same period, from 27 per cent to 15 per cent and 23 per cent to nine per cent respectively. Dr Parker says Active Surveillance has likely become even more common since 2008, when NICE made it a standard treatment option.
Older patients were far more likely to opt for Active Surveillance, instead of immediate radical treatment. Of 1,305 patients who were aged 75 years or over when diagnosed with low-risk disease, 64 per cent were managed with Active Surveillance and just three per cent with radiotherapy and one per cent with surgery.
Treatment choice was also associated with socio-economic status, for example 34 per cent of men living in the most affluent areas opted for surgery compared to 19 per cent of men in the most deprived areas.
Dr Lesley Walker, director of cancer information at Cancer Research UK, said: “This study shows how Active Surveillance is changing the way doctors treat early prostate cancers. Prostate cancer is very common and in many cases it doesn’t cause any problems during a man’s lifetime.
“But it can be difficult for doctors to determine which prostate cancers need treatment and which cases don’t. This system gives more options for men with low risk disease, helping many men to avoid unnecessary treatment altogether.”
The incidence of prostate cancer has more than doubled over the past 20 years, at least in part due to the increased uptake of PSA testing. It has now overtaken lung cancer to become the most common cancer in men, affecting more than 35,000 in the UK every year.
This study was funded by the ICR, Cancer Research UK and the NCRI South of England Prostate Cancer Collaborative, which receives funding from the Department of Health and the Medical Research Council.
Dr Parker is also the UK chief investigator of an international long-term trial comparing the effectiveness of active surveillance with immediate radical treatment, which is currently recruiting up to 2,000 men. Another study of 450 men under active surveillance since 2001 has not found any adverse affects of delaying treatment, and Dr Parker anticipates about two-thirds of these men will avoid the need for treatment completely.
For more information on active surveillance: http://www.icr.ac.uk/about_us/annual_research_report/5867.pdf
The Institute of Cancer Research (ICR)
