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

Carvalho, Tiago M. de; Heijnsdijk, Eveline A.M.; Koning, Harry J. de

doi:10.1002/pros.23352

Cited by 12 publications

(9 citation statements)

References 34 publications

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“…A recent microsimulation study investigated the optimal age at which AS should be stopped. After such an age, further biopsies would provide no further benefit, indicating that a switch to watchful waiting is warranted ( 31 ). The optimal age at which to stop AS was strongly dependent on the disease risk and life expectancy of a patient.…”

Section: Discussionmentioning

confidence: 99%

“…Several simulation studies have been performed aiming to estimate the trade-off between the reduction in number of biopsies taken and the delay in detection of disease reclassification ( 31 - 33 ). Although all studies used different modelling strategies, two studies used data from the Johns Hopkins cohort to calibrate their models ( 33 , 34 ).…”

Section: Protocol Based Monitoring Versus Risk-based Monitoringmentioning

confidence: 99%

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

Nieboer¹,

Tomer²,

Rizopoulos³

et al. 2018

Transl. Androl. Urol.

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Active surveillance (AS) is an important treatment modality aiming to reduce the overtreatment of patients with prostate cancer (PCa) who have a low risk of disease reclassification. After enrolling in AS patients are actively monitored using different diagnostic tests (e.g., prostate specific-antigen, digital rectal exams (DREs), medical imaging, and prostate biopsies). Biopsy is the most burdensome test. We aimed to review schedules for monitoring men on AS. We compare fixed versus risk based dynamic monitoring, where biopsies are scheduled during follow-up based on dynamic risk predictions. Several prediction models and scheduling techniques have been published. All proposed risk prediction models need further external validation. We conclude that risk based, dynamic monitoring is a promising new strategy to further reduce overtreatment in PCa patients.

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Section: Discussionmentioning

confidence: 99%

Section: Protocol Based Monitoring Versus Risk-based Monitoringmentioning

confidence: 99%

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

Nieboer¹,

Tomer²,

Rizopoulos³

et al. 2018

Transl. Androl. Urol.

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“…First, the risk of adverse outcomes because of personalised schedules is quite low because of the low rate of metastases and prostate cancer specific mortality in AS patients (Table 1). Second, studies [8,31] have suggested that after the confirmatory biopsy at 1 year of follow-up, biopsies may be done as infrequently as every 2-3 years, with limited adverse consequences. In other words, longer delays in detecting upgrading may be acceptable after the first negative biopsy.…”

Section: Discussionmentioning

confidence: 99%

Personalised biopsy schedules based on risk of Gleason upgrading for patients with low‐risk prostate cancer on active surveillance

et al. 2020

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To develop a model and methodology for predicting the risk of Gleason upgrading in patients with prostate cancer on active surveillance (AS) and using the predicted risks to create risk-based personalised biopsy schedules as an alternative to one-size-fits-all schedules (e.g. annually). Furthermore, to assist patients and doctors in making shared decisions on biopsy schedules, by providing them quantitative estimates of the burden and benefit of opting for personalised vs any other schedule in AS. Lastly, to externally validate our model and implement it along with personalised schedules in a ready to use web-application. Patients and Methods Repeat prostate-specific antigen (PSA) measurements, timing and results of previous biopsies, and age at baseline from the world's largest AS study, Prostate Cancer Research International Active Surveillance (PRIAS; 7813 patients, 1134 experienced upgrading). We fitted a Bayesian joint model for time-to-event and longitudinal data to this dataset. We then validated our model externally in the largest six AS cohorts of the Movember Foundation's third Global Action Plan (GAP3) database (>20 000 patients, 27 centres worldwide). Using the model predicted upgrading risks; we scheduled biopsies whenever a patient's upgrading risk was above a certain threshold. To assist patients/doctors in the choice of this threshold, and to compare the resulting personalised schedule with currently practiced schedules, along with the timing and the total number of biopsies (burden) planned, for each schedule we provided them with the time delay expected in detecting upgrading (shorter is better). Results The cause-specific cumulative upgrading risk at the 5-year follow-up was 35% in PRIAS, and at most 50% in the GAP3 cohorts. In the PRIAS-based model, PSA velocity was a stronger predictor of upgrading (hazard ratio [HR] 2.47, 95% confidence interval [CI] 1.93-2.99) than the PSA level (HR 0.99, 95% CI 0.89-1.11). Our model had a moderate area under the receiver operating characteristic curve (0.6-0.7) in the validation cohorts. The prediction error was moderate (0.1-0.2) in theGAP3 cohorts where the impact of the PSA level and velocity on upgrading risk was similar to PRIAS, but large (0.2-0.3) otherwise. Our model required re-calibration of baseline upgrading risk in the validation cohorts. We implemented the validated models and the methodology for personalised schedules in a web-application (http://tiny.cc/biopsy). Conclusions We successfully developed and validated a model for predicting upgrading risk, and providing risk-based personalised biopsy decisions in AS of prostate cancer. Personalised prostate biopsies are a novel alternative to fixed one-size-fits-all schedules, which may help to reduce unnecessary prostate biopsies, while maintaining cancer control. The model and schedules made available via a web-application enable shared decision-making on biopsy schedules by comparing fixed and personalised schedules on total biopsies and expected time delay in detecting upgrading.

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“…Although there is guidance about when to start AS, discussion or literature on what clinicians consider or have experienced when decreasing the frequency of testing for AS and/or transitioning to WW is largely absent. There is a commentary, 8 few modelling studies 9 10 and a narrative review. 11 These articles indicate that the decision to de-escalate AS and/or convert to WW is complex and needs to consider age, comorbidities and patient preferences.…”

Section: Introductionmentioning

confidence: 99%

Factors that influence clinicians’ decisions to decrease active surveillance monitoring frequency or transition to watchful waiting for localised prostate cancer: a qualitative study

Lowenstein

Choi

Hoffman³

et al. 2021

BMJ Open

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ObjectiveLittle is known about clinicians’ decision-making about decreasing active surveillance (AS) testing/converting patients to watchful waiting (WW), nor are there any guidelines. The objective of this study was to identify factors that clinicians consider when decreasing AS testing/converting to WW for men with prostate cancer.DesignExploratory qualitative study.SettingAll participants practiced in various institutions in the USA.ParticipantsEligible clinicians had to provide clinical care for patients with prostate cancer in the USA and speak English. Clinicians could be either urologists or radiation oncologists. Of the 24 clinicians, 83% were urologists representing 11 states, 92% were men and 62% were white.MethodsThis qualitative study used data from semi-structured interviews. Purposive sampling was used to ensure geographical variation in the USA. Data collection continued until thematic saturation was achieved. Framework analysis guided coding and identification of themes. Two researchers coded all transcripts independently, met to discuss and reached consensus.ResultsInterviews with clinicians demonstrated that testing or monitoring for AS or transitioning to WW is happening in practice, whether intentionally or unintentionally. Decisions to decrease AS were personalised and tailored to patients’ health status. Life expectancy was the dominant factor that influenced decision, but clinicians were generally hesitant to specify an age when they would decrease AS or transition to WW. Fear that poor adherence could lead to missed progression and concerns about the medico-legal issue of not doing enough were cited as barriers to decreasing AS.ConclusionsThese findings suggest that in certain situations, AS frequency is reduced or transitioned to WW, yet decisions appear to be inconsistent and there are no significant barriers. These findings could inform further areas to explore when drafting recommendations that consider patients’ values and preferences when making decisions about decreasing AS/converting to WW.

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

Abstract: The benefit of AS when compared to CM is strongly dependent on life expectancy and disease risk. Clinicians should take this into account when selecting men to AS, deciding on biopsy frequency and when to stop AS surveillance rounds and transition to CM.

Cited by 12 publications

References 34 publications

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

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

Personalised biopsy schedules based on risk of Gleason upgrading for patients with low‐risk prostate cancer on active surveillance

Factors that influence clinicians’ decisions to decrease active surveillance monitoring frequency or transition to watchful waiting for localised prostate cancer: a qualitative study

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