Use
of
active
surveillance
for
low-
and
favorable
intermediate-risk
prostate
cancer
more
than
tripled
since
2005,
according
to
a
large
study
of
veterans.

In
2005
active
surveillance
accounted
for
27%
of
men
with
low-risk
prostate
cancer
in
the
Veterans
Affairs
Healthcare
System
(VAHCS).
By
2024
the
proportion
had
increased
to
93%.
Among
men
with
favorable
intermediate-risk
prostate
cancer,
use
of
active
surveillance
increased
from
14%
to
61%.

Across
individual
VA
facilities,
overall
surveillance
rates
ranged
from
23%
to
93%.
For
grade
group
(GG)
1
prostate
cancers
diagnosed
from
2015-2024,
active
surveillance
accounted
for
60%
to
100%
of
patients,
except
for
a
single
outlier
facility
with
26%.

Rates
of
active
surveillance/watchful
waiting
in
the
VAHCS
exceeded
those
reported
from
studies
of
community-based
clinical
practices,
reported
Matthew
R.
Cooperberg,
MD,
MPH,
of
the
University
of
California
San
Francisco
(UCSF),
and
colleagues
in


JAMA.

“Prostate
cancer
screening
saves
thousands
of
lives
by
finding
aggressive
cancers
early,
but
it
also
detects
many
slow-growing
cancers
that
do
not
spread,
and
should
not
be
treated
except
in
rare
occasions,”
Cooperberg
said
in
a

press
release.
“Many
experts
are
recommending
that
we
not
even
call
these
‘cancers.'”

The
findings
reflect
a
paradigm
shift
in
the
approach
to
managing
low-risk
prostate
cancer,
according
to
the
authors
of
an

accompanying
editorial.

“These
are
not
marginal
shifts.
They
represent
a
wholesale
change
in
what
guideline-concordant
care
looks
like,”
wrote
Daniel
E.
Spratt,
MD,
of
University
Hospitals
Seidman
Cancer
Center
in
Cleveland,
and
colleagues.
“Randomized
trials,
mature
prospective
cohorts
with
long-term
follow-up,
unified
guideline
support,
and
patient
advocacy
all
converged
to
reverse
a
pattern
of
overtreatment
that
has
been
witnessed
over
the
past
years.”

“Clinicians
came
to
recognize
that
patient
anxiety,
so
often
invoked
to
justify
intervention,
is
something
they
can
address
directly
rather
than
a
reason
to
expose
a
patient
to
the
harms
of
treatment
he
does
not
need,”
they
wrote.
“Here
the
evidence,
and
the
VA
institutions,
created
the
pressure
to
do
the
right
thing,
and
they
held
that
line
against
the
potential
financial
incentives
pervasive
in
other
environments.”

Prostate
cancer
specialists
have
agreed
that
active
surveillance
is
the
preferred
mode
of
management
for
low-risk
and
many
intermediate-risk
prostate
cancers,
as
defined
by
GG
and
prostate-specific
antigen
(PSA),
Cooperberg
and
colleagues
noted
in
their
introduction.
Active
surveillance
“is
essential”
to
achieve
a
favorable
benefit/risk
ratio
for
early
detection.

Such
tumors
have
minimal
potential
to
progress
to
aggressive
or
metastatic
disease,
they
continued.
Despite
support
for
active
surveillance
across
multiple
major
clinical
guidelines,
studies
have
suggested
that
use
of
active
surveillance
for
National
Comprehensive
Cancer
Network
(NCCN)-defined
low-risk
prostate
cancer
remains
suboptimal.
To
provide
comparator
data,
the
investigators
examined
the
incidence
and
quality
of
active
surveillance
as
practiced
in
the
VAHCS,
the
nation’s
largest
integrated
healthcare
system.

The
study
included
all
men
with
NCCN
low-
and
favorable
intermediate-risk
prostate
cancer
diagnosed
from
2005-2024
within
the
VAHCS.
Patient
management
was
classified
as
active
surveillance
or
watchful
waiting
(implying
monitoring
without
curative
intent)
if
a
patient
did
not
receive
treatment
within
15
months
of
a
diagnostic
biopsy
and
had
at
least
one
PSA
value
≥1
ng/mL
during
the
timeframe,
or
if
they
had
a
confirmatory
biopsy
within
3
to
15
months
after
a
diagnostic
biopsy
and
before
any
active
treatment.

A
search
of
the
VAHCS
database
identified
73,042
eligible
patients,
of
whom
38,130
initially
entered
active
surveillance/watchful
waiting.
Overall,
use
of
active
surveillance
more
than
tripled
during
the
study
period
and
more
than
quadrupled
in
the
subgroup
of
patients
with
favorable
intermediate-risk
disease.

In
a
subset
analysis
that
considered
the
reason
for
intermediate-risk
assignment,
use
of
active
surveillance
increased
from
11%
to
55%
for
patients
with
PSA
<10
ng/mL
and
GG2
in
less
than
50%
of
biopsy
cores.
The
rate
increased
from
27%
to
88%
in
patients
with
GG1
and
PSA
10-20
ng/mL.

A
multivariable
analysis
showed
that
the
odds
for
active
surveillance
increased
with
age
(OR
1.43
per
decade,
95%
CI
1.39-1.47,

P<0.001)
and
more
recent
year
of
diagnosis
(OR
1.21
per
year,
95%
CI
1.21-1.22,

P<0.001).
Factors
associated
with
decreased
odds
for
active
surveillance
were
Black
or
African
American
race
(OR
0.95
vs
white,
95%
CI
0.90-0.99,

P<0.001),
Hispanic
or
Latino
ethnicity
(OR
0.85
vs
non-Hispanic,
95%
CI
0.76-0.95,

P=0.003),
GG2
versus
GG1
(OR
0.13,
95%
CI
0.12-0.13,

P<0.001),
Area
Deprivation
Index
score
(OR
0.97
per
quartile,
95%
CI
0.95-0.99),
and
greater
percent
of
positive-result
biopsy
cores
(OR
0.88
per
decile,
95%
CI
0.87-0.89,

P<0.001).

Although
the
study
was
carried
out
in
a
large
integrated
healthcare
system,
adherence
to
key
components
of
disease
monitoring
can
make
active
surveillance
feasible
for
clinical
practice
environments
with
more
limited
resources
than
the
VAHCS,
said
co-author
Grace
Lee,
MD,
also
of
UCSF.

“With
the
caveat
that
active
surveillance
can
be
personalized
to
each
patient
depending
on
their
specific
risk
factors,
PSA
generally
should
not
be
obtained
more
than
every
6
months
(which
can
be
performed
in
local/rural
labs)
and
MRI/biopsy
no
more
frequently
performed
than
once
per
year,”
Lee
told

MedPage
Today.
“If
patients
have
repeat
negative
biopsies,
MRI/biopsy
can
be
spaced
out
even
further.
Given
this,
it
is
very
feasible
to
manage
patients
under
active
surveillance
even
with
limited
healthcare
resources.
Another
critical
part
of
active
surveillance
is
ensuring
a
confirmatory
biopsy
(after
initial
diagnostic
biopsy)
is
performed
generally
within
6-12
months
of
the
initial
diagnostic
biopsy.”

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