International Panel Forms Consensus Best Practices for Active Surveillance in Prostate Cancer

Prostate cancer active surveillance best practices and research priorities as determined by an international panel of experts have been detailed in a new report published in European Urology Oncology. The work was commissioned by Movember, a global charity focused on prostate cancer, testicular cancer, and mental health initiatives for men.

In low-risk and some intermediate-risk localized prostate cancer cases, active surveillance is the recommended course of treatment until testing shows disease that would benefit from treatment. But active surveillance uptake and strategies vary between countries and settings, the authors noted.

In general, active surveillance is intended to minimize the need for treatment and its adverse effects. Patients who would benefit more from active surveillance rather than treatment are identified differently depending on the country, with variation in the use of prostate-specific antigen (PSA) testing, MRI, and biopsy for prostate cancer detection and risk assessment. Collaborative efforts have published guidelines previously, and the panel aimed to build upon these initiatives.

A range of health care professionals and health care researchers formed one panel, and patients with a lived prostate cancer experience were included in another panel within the discussion. The panels came to a consensus on several aspects that should be considered in the decision to offer a patient active surveillance for prostate cancer. The most crucial criteria were Gleason grade and MRI findings, followed by PSA density and PSA.

“This reflects a current gap in the guidelines where, while MRI is recommended before biopsy and therefore MRI data are widely available in clinical practice, the granular details of MRI data (eg, tumor volume) are not specified in risk stratification systems yet,” the authors wrote. “New risk stratification approaches are likely to incorporate MRI data to address this, but widespread data on MRI parameters, including tumor volume, need to be collected and published.”

The panel’s guideline recommendations differed from current best practices in several ways.

First, they concluded that digital rectal examination (DRE) can be omitted when MRI is conducted regularly during active surveillance, as DRE has relatively poor predictive value but significant patient impact. Also, in men whose MRI and PSA kinetics and density are stable during active surveillance, the clinician and patient may consider omitting routine biopsy.

PSA or DRE changes, they concluded, should make biopsy an option rather than leading to immediate biopsy or to a discussion of commencing active treatment. The decision to switch to active treatment should also be the product of discussion between the clinician and patient as well as a combination of clinical parameters, rather than just one parameter.

Finally, men who are appropriate candidates for active surveillance but experience significant psychological consequences related to active surveillance should be offered emotional support before switching to active treatment. This also applies to men who may be at risk of psychological consequences.

“Guidelines often concentrate on the clinical aspects of disease management, while this consensus process explicitly sought to acknowledge important social and psychological determinants of entry into and maintaining participation in active surveillance,” the authors noted. “Having a dedicated lived experience panel was particularly helpful in this regard.”

While the authors noted that the consensus and guidelines represent the thoughts of a limited number of experts included on the panel, the group comprised international experts with a range of experiences in various settings. The lived experience panel also represented a range of experiences, including men who have undergone active treatment.

Where research is concerned, the top research priority for the future was creating a personalized, dynamic, and risk-adapted approach to active surveillance that follows an agreed-upon framework and involves less testing for those who are at a very low risk of progression, the panels agreed. Adapting the approach based on a patient’s specific risk level would differ from current standard guidelines, the authors noted. Addressing care disparities in prostate cancer to ensure all patients eligible to active surveillance are offered the option is another key research priority and theme for health care research overall, the authors concluded.

Reference

Moore CM, King LE, Withingon J, wt al. Best current practice and research priorities in active surveillance for prostate cancer—a report of a Movember international consensus meeting. Eur Urol Oncol. Published online January 27, 2023. doi:10.1016/j.euo.2023.01.003