Estimating the individual benefit of immediate treatment or active surveillance for prostate cancer after screen‐detection in older (65+) men

Abstract

A significant proportion of screen-detected men with prostate cancer is likely to be overtreated, especially in older age groups. We aim to find which groups of screen-detected older men (651) benefit the most from Immediate Radical Treatment or Active Surveillance (AS) for prostate cancer, depending on age, screening history, health status and prostate cancer stage at detection. We used a microsimulation model (MISCAN) of the natural history of prostate cancer based on ERSPC data. Individual life histories are simulated with US comorbidity lifetables based on a random sample of MEDICARE data. Different screening histories are simulated and we count outcomes for men screen-detected from ages 66 to 72. For immediately treated men with low-risk disease ( T2a, Gleason 6) the probability of overtreatment ranges from 61% to 86% decreasing to between 37 and 46%, if they are assigned to AS. For intermediate risk men ( T2, Gleason 3 1 4) overtreatment ranges from 23 to 60%, which reduces to between 16 and 31% for AS. For high risk men (T3, or ! Gleason 4 1 3), overtreatment ranges from 11 to 51%. The disease stage at screen-detection is a critical risk factor for overtreatment. For low risk men, AS seems to significantly reduce overtreatment at a modest cost. For intermediate risk men, the decision between immediate treatment or AS depends on age and comorbidity status. Men screen-detected in a high risk disease stage may benefit from immediate treatment even beyond age 69.Overdiagnosis consists of the detection of cancer that would not develop into clinical cancer in absence of screening, or eventually be life-threatening. If an overdiagnosed man is referred for radical treatment then he is considered to be overtreated. In a context of limited healthcare resources, it is crucial to identify which patients are at risk of overtreatment and therefore could be better handled by Active Surveillance (AS) or be left untreated.Estimates of overdiagnosis in prostate cancer can vary considerably. Depending on, whether an excess incidence approach is used or, on the specific microsimulation model, estimates range between 23 and 60% of screen-detected men.

Active surveillance: a review of risk-based, dynamic monitoring

“…If a disease reclassification is observed, curative treatment may often be initiated. Several simulation studies have shown benefit of AS compared to immediate treatment for some patient groups ( 4 - 6 ).…”

When should active surveillance for prostate cancer stop if no progression is detected?

“…The aim of this study is to determine at which age it is safe and more cost‐effective to leave AS and transition to a CM context, for different age and disease risk groups. We use a previously validated microsimulation model of prostate cancer screening and AS, and compare the incremental cost‐effectiveness of each additional AS biopsy round, compared to CM.…”