Watchful waiting in prostate cancer becoming more popular

By Dr. Ananya Mandal, MDFeb 11 2019

In 2010, the US National Comprehensive Cancer Network guidelines suggested that patients with stable and low-risk prostate cancers could be managed with active surveillance or watchful waiting (AS/WW). AS/WW was considered to be a safe and effective alternative to aggressive surgery to remove the prostate and radiation therapy.

A new study looked at the trends in management of prostate cancer between 2010 and 2015 and found that this trend of AS/WW has indeed caught up with the treating doctors. The study results from researchers at Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, appeared in the latest issue of the journal JAMA.

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A team of researchers, for this study, looked at management of localized prostate cancer among 164,760 men between 2010 and 2015. They obtained this data from the national database of cancer statistics - Surveillance, Epidemiology, and End Results. In 2010 the use of AS/WW was 14.5 percent and it rose to 42.1 percent in 2015, write the researchers. This mode of management became more popular they write. The use of this approach also rose in men with intermediate-risk disease and remained similar among men with high-risk prostate cancer.

• They noted that the numbers of radical prostatectomy surgery reduced from 47.4 percent in 2010 to 31.3 percent in 2015. Radiation therapy use declined from 38 percent in 2010 to 26.6 percent in 2015.
• Among cases of intermediate-risk cancer the rates of AS/WW rose from 5.8 percent to 9.6 percent. Similarly among these cases prostatectomy decreased from 51.8 percent to 50.6 percent and radiotherapy fell from 42.4 percent to 39.8 percent.
• Among those with high-risk disease active surveillance was unchanged (1.9 percent to 2.2 percent) while prostatectomy increased from 38  percent to 42.8 percent and radiotherapy decreased from 60.1 percent to 55 percent in 2010 and 2015 respectively.

The researchers explain that compared with high-risk or intermediate-risk cancers, low-risk prostate cancer grows very slowly and thus it can be considered to be an alternative treatment option to surgery and radiation therapy. They explain that surgery and radiation therapy are fraught with side effects such as bleeding, nerve damage, urine or stool leakage, infections, erectile dysfunction etc.

Brandon Mahal, lead author and a clinical fellow in radiation oncology at Dana-Farber Cancer Institute said in a statement, “We found that in low-risk prostate cancer, active surveillance use nearly tripled... Overall, these numbers are a good sign and a good thing. From 2010 to 2015, there's been a lot of new evidence -- the highest level of evidence we can get in medicine, which are prospective trials and some of them randomized trials -- that have shown that active surveillance, conservative approaches or non-treatment approaches of low-risk prostate cancer have very favourable outcomes.” He called this study a “benchmark”.

Prostate cancer is the second most common cancer among men across the world. According to the World Cancer Research Fund, there were 1.3 million newly diagnosed cases of prostate cancer in 2018. National Cancer Institute states that in the US 11.2 percent men are at risk of getting prostate cancer at some point in their lives.