Dramatic Increase in Active Surveillance Use for Prostate Cancer

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.”