In a recent study published in the Journal of Urology, researchers described the uptake, discontinuation, and variation of active surveillance (AS) in prostate cancer (PC) by provider- and patient-level characteristics. The findings provide new evidence for how long PC patients can expect to remain on AS, as well as factors affecting the likelihood of transition to definitive treatment.

This observational, population-based study used linked administrative databases and pathology reports to identify all men diagnosed with Gleason score <6 PC between January 1, 2008, and December 31, 2014, in Ontario, Canada. The Cochran-Armitage test was used for AS trend over time. Treatment-free survival was assessed using cumulative incidence function. Factors associated with discontinuation of AS were evaluated using Cox proportional-hazard models.

The researchers found that AS was the initial management strategy for 8,541 cases (51%). Use of AS significantly expanded from 38% in 2008 to 69% in 2014 (P = .001). Men on AS were significantly older (age 64 years, standard deviation [SD] 8.0) than those on initial treatment (age 62 years, SD 7.7; P = .001). After an average follow up of 48 months, 4,337 (51%) patients had terminated AS. Treatment-free survival for AS patients at 1, 3, and 5 years were 85%, 58%, and 52%, respectively. The average time to definitive treatment after initial AS was 16 months (interquartile range: 11-25 months).

It was discovered that the factors linked to AS discontinuation were younger age at diagnosis, year of diagnosis, greater number of comorbidities, treatment at academic center, treatment by physician and institution in the highest-volume tertile, and adverse cancer-specific characteristics (higher prostate-specific antigen [PSA], larger number of positive cores, and higher percentage of core involvement at diagnosis). The authors concluded that although the uptake of AS significantly expanded over time, there was a relatively high rate of discontinuation over 5 years.

The factors associated with transition to definitive treatment were younger age, care provided by higher-volume physicians and institutions, higher PSA, and greater PC volume at diagnosis. The researchers noted that their results may help guide policy making and aid in the development of quality indicators, and targeted continued education for physicians and patients embarking on AS to determine realistic expectations.

Lead author Antonio Finelli, MD, MSc, FRCSC, of the University of Toronto, stated, "These population-based data show that while the number of patients initiating active surveillance has significantly increased over time, follow-up shows a relatively high rate of transitioning to other forms of treatment within 5 years." Dr. Finelli added, "Current practice may be improved by the development of quality indicators, targeted continuing education for physicians, and patient education with shared decision making at the onset of active surveillance."

The authors stated that their findings have critical implications for managing low-risk PC, including patient counseling and setting realistic expectations for men who are considering their treatment options. They emphasized the "dire need" to develop more specific tests and imaging studies to guide selection and monitoring of men who choose monitoring over immediate treatment for favorable-risk PC. 

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