'Low risk' prostate cancer slipping through the cracks

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Almost three quarters of men diagnosed with “low risk” prostate cancer are not being followed up along the protocol developed to detect signs of disease progression, according to Australian research. The study found men were more likely to be adequately followed up if they were diagnosed in a private hospital compared with a public hospital.

Journal/conference: Medical Journal of Australia

DOI: 10.5694/mja17.00559

Organisation/s: Monash University, Peter MacCallum Cancer Centre, The University of Melbourne

Media Release

From: Medical Journal of Australia (MJA)


ALMOST three quarters of men diagnosed with “low risk” prostate cancer are not being followed up in compliance with the active surveillance protocol developed to detect signs of disease progression, according to research published online by the Medical Journal of Australia.

The objectives of active surveillance are to avoid unnecessary treatment, but also to monitor men with low risk cancer according to a protocol that “facilitates recognition of progression which justifies deferred radical treatment with curative intent”, wrote the study authors, led by Associate Professor Sue Evans, Head of the Clinical Registry Unit, and Director of the Centre of Research Excellence in Patient Safety at Monash University.

“The recommended frequency for measuring prostate-specific antigen (PSA) levels ranges from every 3 to every 6 months, and the European Association of Urology guidelines acknowledge that the available evidence is inadequate for defining optimal timing,” Evans and colleagues wrote. “It is generally accepted, however, that the first follow-up biopsy should be undertaken within 12 months of diagnosis; the recommended timing of subsequent biopsies ranges from annually to once every 5 years.”

The researchers analysed data for men diagnosed with prostate cancer between August 2008 and December 2014, aged 75 years or less at diagnosis, who were managed by active surveillance for at least 2 years, and with an International Society of Urological Pathology (ISUP) grade of 3 or less (Gleason score no worse than 4+3=7). The main outcome measure was adherence to an active surveillance schedule consisting of at least three PSA measurements and at least one biopsy in the 2 years following diagnosis.

“Of 1635 men eligible for inclusion in the analysis, 433 (26.5%) adhered to the active surveillance protocol,” they wrote.

“The significant predictor of adherence … was being diagnosed in a private hospital (v public hospital: adjusted odds ratio [aOR], 1.83; 95% CI, 1.42–2.37; P < 0.001). Significant predictors of non-adherence included being diagnosed by transurethral resection of the prostate or transperineal biopsy rather than transrectal ultrasound biopsy (TRUS), and being 66 years of age or more at diagnosis.

“Active surveillance was not implemented according to published protocols in 73.5% of men diagnosed with low risk prostate cancer in this Victorian cohort study.”

The reasons for the non-compliance “may reflect patient-, clinician-, and health service-related factors”, the authors wrote.

“If they are not being followed appropriately according to active surveillance protocols, men may miss the opportunity to be treated with curative intent.

“To improve adherence, a multifaceted approach may be required, including an education campaign that highlights the need for men to undergo regular PSA assessment and prostate biopsy,” they concluded.

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The Medical Journal of Australia is a publication of the Australian Medical Association.


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