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HomeNewsRadical Prostatectomy Shifting to Higher-Risk Cases in Era of Active Surveillance

Radical Prostatectomy Shifting to Higher-Risk Cases in Era of Active Surveillance

NEW YORK (Reuters Health) – There has been a trend towards decreasing use of radical prostatectomy (RP) in men with low- and favorable-intermediate-risk prostate cancer and increasing use of RP in men with unfavorable-intermediate- and high-risk disease, according to a time-trends analysis.

The findings suggest that urologists are “doing a better job at matching intensity of treatment with disease aggressiveness,” Dr. Timothy J. Daskivich of Cedars-Sinai Medical Center, in Los Angeles, told Reuters Health by email.

The findings are based on a nationally representative sample of 5,736 men treated with RP at eight Veterans Affairs hospitals from 2000 to 2017.

During the 18-year study period, there were decreases in the proportion of low-risk tumors (from 51% to 7%), favorable-intermediate-risk tumors (from 61% to 41%), and low-volume favorable-intermediate-risk tumors (from 35% to 7%) treated with RP.

These changes were accompanied by an increase in the use of RP for unfavorable-intermediate-risk tumors (from 30% to 41%) and high-risk tumors (from 18% to 33%), Dr. Daskivich and colleagues report in JAMA Network Open.

The results show that the tumor-risk case mix among men receiving RP in the VA healthcare system has “drastically” changed in the active-surveillance era, they note.

“Men with low- and favorable-intermediate-risk prostate cancer can often be safely watched until their disease grade increases using an active-surveillance approach involving serial PSAs, prostate MRIs, and intermittent rebiopsy. Many of these men will not progress over time and will avoid the side effects of radical prostatectomy,” Dr. Daskivich told Reuters Health.

“Conversely, men with unfavorable-intermediate- and high-risk disease stand to benefit most from upfront radical prostatectomy. The fact that urologists are shifting their surgical focus to higher-risk disease represents a major advance in improving quality of life of men with the disease,” Dr. Daskivich added.

In a phone interview with Reuters Health, Dr. Ash Tewari, professor and system chair of urology at Mount Sinai Health System, in New York, said the “bottom-line message is that medical education on prostate-cancer management and endorsement of active surveillance has made a positive impact on the treatment process.”

In this large cohort, “rates of surgical intervention went down for those who had a very low-risk prostate cancer, and it went up for intermediate-risk prostate cancers. That is a right thing to do, because a lot of very-low-risk and low-risk prostate cancer can be managed by active surveillance,” said Dr. Tewari, who wasn’t involved in the study.

However, Dr. Daskivich and colleagues also observed that the proportion of men treated with RP with life expectancy (LE) of less than 10 years increased 9% during the study period.

“Despite more appropriately reserving the use of RP for men with higher-risk tumors, urologists still appear to be overtreating men with LE at a similar rate over time,” Dr. Daskivich commented.

“If anything, our data suggest that RP rates for men with limited LE may even be slightly increasing over time. Men with limited LE are least likely to live long enough to benefit from treatment, as most prostate cancers are slow-growing, and are most likely to experience side effects after radical prostatectomy,” he added.

Dr. Daskivich noted that LE is a component of prostate-cancer treatment guidelines as the first consideration across all tumor risk categories. Yet, LE is a more difficult concept to calculate than tumor risk, since it requires consideration of age, comorbidity, and other lifestyle factors.

To address this, Dr. Daskivich and others have created tools to predict LE, like the prostate cancer comorbidity index (PCCI), which is a weighted score based on age and comorbidity that has been validated to predict LE across a sample of 181,000 men in the VA.

“In cases where limited LE may be a consideration, providers should take the time to use this tool (or one like it) to inform their treatment consultation with the patient. We hope that use of these tools will lead to more informed decisions and ultimately reduce unnecessary over treatment of prostate cancers in men with limited LE,” Dr. Daskivich told Reuters Health.

“There are efforts towards calculating and getting a feel about life expectancy,” Dr. Tewari told Reuters Health. “I look at the patient’s overall health and coordinate with their internists, cardiologists, to make an assessment. My rule of thumb is if someone is being brought into my office by his father, he is going to be okay. Meaning if his father lived that long, bringing him to the office, that being that patient is okay.”

“You have to make an individual decision for each patient; you can’t be very rigid and the patient’s own interest needs to be targeted,” said Dr. Tewari.

The study was funded by the National Cancer Institute. The authors have indicated no relevant conflicts of interest.

SOURCE: JAMA Network Open, online June 3, 2021.

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