Active Surveillance for Low and Intermediate Risk Prostate Cancer: Opinions of North American Genitourinary Oncology Expert Radiation Oncologists

A national questionnaire survey of Japanese urologists on active surveillance for low- and intermediate-risk prostate cancer

OBJECTIVE

To conduct a national questionnaire survey of Japanese urologists on active surveillance (AS) for low- and intermediate-risk prostate cancer (PCa).

METHODS

A questionnaire was sent to 922 Japanese Urological Association Teaching Base Hospitals. The items included were years of experience as a urologist, sex, workplace, treatment equipment owned, specialty area of daily practice, specialty area of urological cancer, and six hypothetical cases of AS. The cases were categorized by the following Gleason scores: 3 + 3 low risk of PCa, 3 + 4 intermediate risk, and 4 + 3 intermediate risk, with or without comorbidities for each case. Comorbidities were defined as cardiovascular diseases or illnesses warranting anticoagulant therapy.

RESULTS

Altogether, 1962 questionnaires were analyzed. Responses were almost equally distributed among all age groups. Workplaces included general hospitals (49.4%), university hospitals (40.3%), and cancer centers (4.2%). Percentages of proposed AS for low risk/no comorbidity, low risk/with comorbidity, intermediate-risk 3 + 4/no comorbidity, intermediate risk 3 + 4/with comorbidity, intermediate risk 4 + 3/no comorbidity, and intermediate risk 4 + 3/with comorbidity were 90.5%, 90%, 39.5%, 48.7%, 15%, and 22%, respectively. Analysis of the correspondents' backgrounds showed that the more the urologists' years of experience, the less they were to advise AS of low-risk patients. In the presence of comorbidities, urologists across all age groups tended to propose AS, even in the same Gleason grade group. Cancer center urologists recommended AS more often than their counterparts at general and university hospitals.

CONCLUSIONS

Approximately 40% of urologists proposed AS for intermediate-risk cases, confirming that AS for intermediate-risk patients is being considered in Japan.

Active surveillance protocol in prostate cancer in Portugal

OBJECTIVE

To examine clinical practice patterns in locally managing patients under an active surveillance protocol among Portuguese urologists.

INTRODUCTION

Prostate cancer (PCa) is a heterogeneous disease with many prostate adenocarcinomas being indolent and a low probability of ever causing symptoms or death. Active surveillance (AS) is a form of conservative management aimed to reduce over-treatment for low-risk PCa patients. Over the years, experience with AS has grown considerably and is now standard in some countries, however a universal protocol still does not exist.

METHODS

Nationwide anonymous e-survey concerning habits and practices on AS among Portuguese urologists, that consisted of twelve questions and was sent electronically to all 368 current members of the Portuguese Urological Association.

RESULTS

56 urologists were surveyed (15.21% answer rate), evenly distributed geographically and allocated according to years of experience as well as number of PCa patients managed monthly. The vast majority of respondents recommends AS to their patients, particularly ISUP grade 1 patients, whose PSA serum level is bellow 20 ng/mL. Observance of AS programs by patients was not in question but concerns exist over psychological morbidity while harboring disease. Majority believed that international guidelines surveillance protocols were adequate and sufficient, but there are some constraints concerning availability of periodic MRIs and re-biopsy needs.

CONCLUSIONS

AS seems to be sustained in urologist clinical practice, although patients still lag to adhere and choose for active treatment. AS may not be an easy choice for patients and clinicians due to uncertainty of disease progression, risk of loss to follow-up and repeated biopsies but is also a cause for anxiety, depression, uncertainty and a perception of danger.

Implications of a Novel Biopsy Downloading System on Prostate Cancer Detection Rate, Surveillance and Focal Therapy - A Prospective Study

OBJECTIVE

To examine the SmartBx, a novel biopsy downloading system, allowing downloading of biopsy cores with maximal core preservation as prostate biopsy sampling lacks preservation of core configuration & orientation.

METHODS

We prospectively collected cores from TRUS biopsy patients. Half were collected using the SmartBx & half using standard downloading. We measured length of the first ∼3200 cores through various pathology steps and within core cancer length in 160 SmartBx cores. We compared core length, yield (% of core available for final analysis/ original core on needle) and cancer detection rate between SmartBx and standard cores. T-test or chi-square were used for analysis.

RESULTS

6014 cores were collected from 429 patients. Core length (12.3mm vs. 10mm; P<.01) and core yield (77.5% vs. 62.2%; P<.01) were significantly higher using the SmartBx compared to standard method, respectively. Cancer detection rate was significantly higher using the SmartBx for patients with PSA<10 (10.1% vs. 7.96%; n=2080 & n=2073, respectively; P<.016). Other subgroups showed non-significant higher detection rate for SmartBx cores. We noticed higher detection rate of clinically significant prostate cancer. Within core cancer length in 160 SmartBx cores was significantly lower compared to standard positive whole cores (4.45mm vs. 10.9mm; P<.001). Assuming cancer site a perfect sphere, disease volume was 11-fold lower for within core compared to entire core (46.1mm vs. 679.9mm; P<.0001).

CONCLUSIONS

SmartBx results in significant higher core length, yield and cancer detection rate. Precise localization of within core tumor foci allows significant reduction in tumor volume.

Active surveillance for intermediate-risk prostate cancer: yes, but for whom?

PURPOSE OF REVIEW

Active surveillance is becoming more widely accepted as an initial management option for carefully selected men with favorable intermediate-risk prostate cancer (PCa). As prospective active surveillance cohorts mature sufficiently to begin evaluating longer-term outcomes, consensus on more precise evidence-based guidelines is needed to identify the patient cohorts who may be safely managed with active surveillance and what the ideal surveillance protocol entails.

RECENT FINDINGS

Long-term outcomes updates have suggested a trend toward worse 15-year survival outcomes for intermediate-risk patients on active surveillance compared with definitive treatment, but 'intermediate-risk' is a broad category and there is a subset of favorable intermediate-risk patients for whom survival outcomes remain equivalent. Promising updates to current risk stratification include consideration of genomic classifiers, advanced imaging and more nuanced interpretation of biopsy results.

SUMMARY

Despite widespread acknowledgement of the pitfalls of overtreatment in clinically localized PCa, utilization of active surveillance in the intermediate-risk population remains marginal, in part due to the absence of easily interpretable consensus recommendations. As more long-term outcomes data become available for this subgroup, the field is now poised to refine the definition of favorable intermediate-risk patients for whom active surveillance is a safe, evidence-based first-line management option.

Is moderate hypofractionation accepted as a new standard of care in north america for prostate cancer patients treated with external beam radiotherapy? Survey of genitourinary expert radiation oncologists

Introduction:

Several recent randomized clinical trials have evaluated hypofractionated regimens against conventionally fractionated EBRT and shown similar effectiveness with conflicting toxicity results. The current view regarding hypofractionation compared to conventional EBRT among North American genitourinary experts for management of prostate cancer has not been investigated.

Materials and Methods:

A survey was distributed to 88 practicing North American GU physicians serving on decision - making committees of cooperative group research organizations. Questions pertained to opinions regarding the default EBRT dose and fractionation for a hypothetical example of a favorable intermediate - risk prostate cancer (Gleason 3 + 4). Treatment recommendations were correlated with practice patterns using Fisher's exact test.

Results:

Forty - two respondents (48%) completed the survey. We excluded from analysis two respondents who selected radical hypofractionation with 5 – 12 fractions as a preferred treatment modality. Among the 40 analyzed respondents, 23 (57.5%) recommend conventional fractionation and 17 (42.5%) recommended moderate hypofractionation. No demographic factors were found to be associated with preference for a fractionation regimen. Support for brachytherapy as a first choice treatment modality for low - risk prostate cancer was borderline significantly associated with support for moderate hypofractionated EBRT treatment modality (p = 0.089).

Conclusions:

There is an almost equal split among North American GU expert radiation oncologists regarding the appropriateness to consider moderately hypofractionated EBRT as a new standard of care in management of patients with prostate cancer. Physicians who embrace brachytherapy may be more inclined to support moderate hypofractionated regimen for EBRT. It is unclear whether reports with longer follow-ups will impact this balance, or whether national care and reimbursement policies will drive the clinical decisions. In the day and age of patient - centered care delivery, patients should receive an objective recommendation based on available clinical evidence. The stark division among GU experts may influence the design of future clinical trials utilizing EBRT for patients with prostate cancer.

Use and early mortality outcomes of active surveillance in patients with intermediate-risk prostate cancer

BACKGROUND

Certain patients with intermediate-risk prostate cancer (PCa) may be appropriate candidates for active surveillance (AS). In the current study, the authors sought to characterize AS use and early mortality outcomes for patients with intermediate-risk PCa in the United States.

METHODS

The novel Surveillance, Epidemiology, and End Results Active Surveillance/Watchful Waiting database identified 52,940 men diagnosed with National Comprehensive Cancer Network intermediate-risk PCa (cT2b-c, Gleason score of 7, or a prostate-specific antigen level of 10-20 ng/mL) and actively managed (AS, radiotherapy, or radical prostatectomy) from 2010 through 2015. The Cuzick test assessed AS time trends, and logistic multivariable regression characterized features associated with AS. Fine-Gray and Cox modeling determined PCa-specific mortality (PCSM) and overall survival, respectively.

RESULTS

The rate of AS increased from 3.7% in 2010 to 7.3% in 2015, and from 7.2% to 11.7% among men aged ≥70 years. Among men with favorable and unfavorable intermediate-risk disease, the use of AS increased from 7.2% to 14.9% and from 2.2% to 3.8%, respectively (all P value for trend, <.001). The mean age of those patients managed with AS decreased from 69.9 years to 67.9 years (P = .0004). Factors found to be associated with AS included favorable risk disease; black race; higher socioeconomic status; older age; and diagnosis in the West, Northwest, or Midwest regions of the United States. The 5-year PCSM rate was comparable to AS versus treatment among patients with low-risk and favorable intermediate-risk disease, but was worse with AS among those with unfavorable intermediate-risk disease (PCSM, 1.3% vs 0.5%; adjusted hazard ratio, 2.48 [95% CI, 1.11-5.50; P = .026]) and intermediate-risk disease overall (PCSM, 1.1% vs 0.4%; adjusted hazard ratio, 2.34 [95% CI, 1.25-4.37; P = .008]).

CONCLUSIONS

The use of AS for patients with intermediate-risk PCa is increasing across the United States, particularly for older men and those with favorable intermediate-risk disease. Early estimates of cancer-specific and overall mortality rates are low with AS, although significantly higher compared with treatment.

Dramatic polarization in genitourinary expert opinions regarding the clinical utility of positron emission tomography (PET) imaging in prostate cancer

Objectives:

To ascertain the opinions of North American genitourinary (GU) experts regarding inclusion of technologies such as prostate - specific membrane antigen (PSMA) and C – 11 choline positron emission tomography (PET) into routine practice.

Materials and Methods:

A survey was distributed to North American GU experts. Questions pertained to the role of PSMA and C – 11 PET in PCa management. Participants were categorized as “supporters” or “opponents” of incorporation of novel imaging techniques. Opinions were correlated with practice patterns.

Results:

Response rate was 54% and we analyzed 42 radiation oncologist respondents. 17 participants (40%) have been in practice for > 20 years and 38 (90%) practice at an academic center. 24 (57%) were supporters of PSMA and 29 (69%) were supporters of C – 11. Supporters were more likely to treat pelvic nodes (88% vs. 56%, p < 01) and trended to be more likely to treat patients with moderate or extreme hypofractionation (58% vs. 28%, p = 065). Supporters trended to be more likely to offer brachytherapy boost (55% vs. 23%, p = 09), favor initial observation and early salvage over adjuvant radiation (77% vs. 55%, p = 09), and to consider themselves expert brachytherapists (69% vs. 39%, p = 09).

Conclusions:

There is a polarization among GU radiation oncology experts regarding novel imaging techniques. A correlation emerged between support of novel imaging and adoption of treatment approaches that are clinically superior or less expensive. Pre - existing biases among GU experts on national treatment - decision panels and leaders of cooperative group studies may affect the design of future studies and influence the adoption of these technologies in clinical practice.

Adjuvant vs. salvage radiation therapy in men with high-risk features after radical prostatectomy: Survey of North American genitourinary expert radiation oncologists

INTRODUCTION

The management of patients with high-risk features after radical prostatectomy (RP) is controversial. Level 1 evidence demonstrates that adjuvant radiation therapy (RT) improves survival compared to no treatment; however, it may overtreat up to 30% of patients, as randomized clinical trials (RCTs) using salvage RT on observation arms failed to reveal a survival advantage of adjuvant RT. We, therefore, sought to determine the current view of adjuvant vs. salvage RT among North American genitourinary (GU) radiation oncology experts.

METHODS

A survey was distributed to 88 practicing North American GU physicians serving on decision-making committees of cooperative group research organizations. Questions pertained to opinions regarding adjuvant vs. salvage RT for this patient population. Treatment recommendations were correlated with practice patterns using Fisher's exact test.

RESULTS

Forty-two of 88 radiation oncologists completed the survey; 23 (54.8%) recommended adjuvant RT and 19 (45.2%) recommended salvage RT. Recommendation of active surveillance for Gleason 3+4 disease was a significant predictor of salvage RT recommendation (p=0.034), and monthly patient volume approached significance for recommendation of adjuvant over salvage RT; those seeing <15 patients/month trended towards recommending adjuvant over salvage RT (p=0.062). No other demographic factors approached significance.

CONCLUSIONS

There is dramatic polarization among North American GU experts regarding optimal management of patients with high-risk features after RP. Ongoing RCTs will determine whether adjuvant RT improves survival over salvage RT. Until then, the almost 50/50 division seen from this analysis should encourage practicing clinicians to discuss the ambiguity with their patients.