Uptake of Active Surveillance for Very-Low-Risk Prostate Cancer in Sweden

Abstract

Importance Active surveillance is an important option to reduce prostate cancer overtreatment, but it remains underutilized in many countries. Models from the United States show that greater use of active surveillance is important for prostate cancer screening to be cost-effective. Objectives To perform an up-to-date, nationwide, population-based study on use of active surveillance for localized prostate cancer in Sweden. Design Cross-sectional study in the National Prostate Cancer Register (NPCR) of Sweden from 2009 through 2014. Setting The NPCR has data on 98% of prostate cancers diagnosed in Sweden and has comprehensive linkages to other nationwide databases. Participants Overall, 32 518 men with a median age of 67 years were diagnosed with favorable-risk prostate cancer, including 4 693, 15 403 and 17 115 men with very-low-risk (subset of the low-risk group) (clinical stage, T1c; Gleason score, ≤6; prostate-specific antigen [PSA], <10 ng/ml; PSA density <0.15ng/mL/cm3; and <8-mm total cancer length in ≤4 positive biopsy cores), low-risk (including all men in the very-low-risk group) (T1–T2; Gleason score, ≤6; and PSA, <10ng/mL), and intermediate-risk disease (T1–T2 with Gleason score, 7 and/or PSA, 10–20ng/mL). Exposures Diagnosis with favorable-risk prostate cancer Major Outcome Utilization of active surveillance Results The use of active surveillance increased in men of all ages from 57% (380 of 665) to 91% (939 of 1027) for very-low-risk prostate cancer and from 40% (1159 of 2895) to 74% (1951 of 2644) for low-risk prostate cancer, with the strongest increase occurring from 2011 onward. Among men aged 50 to 59 years, 88% (211 of 240) with very-low-risk and 68% (351 of 518) with low-risk disease chose active surveillance in 2014. Use of active surveillance for intermediate-risk disease remained lower, 19% (561 of 3030) in 2014. Conclusions and Relevance Active surveillance has become the dominant management for low-risk prostate cancer among men in Sweden, with the highest rates yet reported and almost complete uptake for very-low-risk cancer. These data should serve as a benchmark to compare the use of active surveillance for favorable-risk disease around the world.

Can active surveillance really reduce the harms of overdiagnosing prostate cancer? A reflection of real life clinical practice in the PRIAS study

“…Of the 30 (6%) patients who No. of follow-up visits 11 [5][6][7][8][9][10][11][12][13][14][15][16][17][18] Data presented as median (IQR) or n (%). PSA, prostate specific antigen; IQR, interquartile range.…”

“…Although PSA screening leads to a PCa mortality reduction, overdiagnosis and overtreatment of these low-risk PCa patients are still a substantial concern (1-4). To prevent overtreatment, active surveillance (AS) is increasingly recognized as a favorable alternative to direct radical therapy for men with low-risk PCa (5)(6)(7)(8). Considering all relevant data, the US Preventive Services Task Force (USPSTF) has recently proposed to endorse physicians to counsel men on PSA screening (9).…”

Public online reporting from a nationwide population‐based clinical prostate cancer register

“…For example, the choice of primary treatment strategy at all Swedish hospitals for men with very‐low‐risk prostate cancer in 2017 is shown in Fig. 1 6.…”

“…Data from each private healthcare provider are shown only when one single healthcare region is used as the source population. Very‐low‐risk prostate cancer was defined as clinical stage T1c, Gleason Grade Group 1, PSA level of <10 ng/ mL , PSA density <0.15 ng/ mL , <8 mm total cancer length in ≤4 positive biopsy cores 6. Figure based on data on men diagnosed in 2017 reported up to 8 March 2018.…”

The National Prostate Cancer Register of Sweden

“…There has been a subsequent strong increase in the use of active surveillance for men with low-risk prostate cancer from 40% in 2009 up to 74% in 2014 [12]. An even stronger decrease was observed for very low-risk prostate cancer (not N1or M1, stage T1c, Gleason Grade Group 1, PSA density less than 0.15/ng/ml/cm 3 , four positive cores or fewer, and less than 8 mm of cancer in biopsies) [13] up from 57% in 2009 to 91% in 2014.…”