Five-year nationwide follow-up study of active surveillance for prostate cancer

Abstract

Background: Active surveillance (AS) is an important yet underutilized strategy to reduce prostate cancer (PCa) overtreatment.

Objective: To examine the 5-yr outcomes of AS in a population-based setting.

Design, setting, and participants: From the National Prostate Cancer Register of Sweden, we identified 11 726 men ≤70 yr diagnosed with very low-risk to intermediate-risk PCa from 2003 to 2007 who completed 5 yr of follow-up. Of these men, 1729 (15%) chose AS for the primary management strategy.

Outcome measurements and statistical analysis: We calculated the probability of discontinuation of AS over time, and Cox proportional hazards models were used to determine factors associated with discontinuation. Reasons for discontinuation were assessed by data extraction from medical charts.

Results and limitations: By 5 yr, 64% of the men remained on AS. Predictors of discontinuation were younger age, fewer comorbidities, more education, higher prostate-specific antigen (PSA), and clinical stage T2 disease; marital status did not predict discontinuation. In a subset with data on the reason for discontinuation (86%), 20% of men discontinued because of patient preference, 52% because of PSA progression, 24% because of biopsy progression, and 3% for other reasons.

Conclusions: In a population-based setting, the majority of men remained on AS at 5 yr. However, one-fifth of the men who discontinued AS did so for nonbiologic reasons. Thus, there is a need for support and counseling for men to continue AS in the absence of signs of progression to improve adherence to AS and decrease overtreatment.

Patient summary: Active surveillance (AS) is an important option to delay or avoid treatment for men with favorable prostate cancer features. This study shows that at 5 yr, 64% of men across an entire population remained on AS. We concluded that AS is a durable option and that counseling may be useful to promote adherence for men without progression.

Keywords: Active surveillance; Adverse pathology; Predictors; Prostate cancer; Upgrading.

Fig. 1

Time to discontinuation of active surveillance in the overall population and by clinical risk category in the National Prostate Cancer Register of Sweden. Dx = diagnosis.

Fig. 2

Time to discontinuation of active surveillance by reason for discontinuation (biopsy/prostate-specific antigen progression, patient preference, or other reasons). Dx = diagnosis; PSA = prostate-specific antigen.