Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyAugust 2024
During seven years, roughly half of patients maintained their low-grade classification, and only 0.1% died of prostate cancer.
A randomised trial has documented favourable longterm outcomes for patients with low-grade prostate cancer who initially undergo active surveillance rather than definitive treatment (NEJM JW Gen Med Apr 1 2023 and N Engl J Med 2023; 388: 1547-1558). However, in real-world practice, adherence to a structured protocol is not always optimal. In this prospective observational study, researchers at 10 US and Canadian academic medical centres enrolled 2155 men (median age, 63 years) who were managed with active surveillance. About 85% of the cases were classified as low or very low risk, and 15% were favourable intermediate risk. Protocol-directed follow up involved prostate specific antigen (PSA) testing every three to six months, confirmatory biopsies at six to 12 months after diagnosis and subsequent biopsies every two years after diagnosis. Adherence to the protocol was roughly 90%.
At a median follow up of 7.2 years, about half of patients maintained their low-grade classification and received no treatment. Cancer grade was reclassified in 43% of participants, and 49% underwent radiotherapy or surgery. Progression to metastatic cancer occurred in 21 patients (1%), and three patients died of prostate cancer.
Comment: Although a fairly high proportion of these patients were eventually reclassified to having highergrade disease, the important finding is that about half were not reclassified, and only 0.1% died of metastatic disease. Another key point is the high level of adherence to protocol-directed follow up PSA testing and biopsies, something that does not necessarily happen in practices with less-structured active surveillance.
Thomas L. Schwenk, MD, Professor Emeritus, Family and Community Medicine, University of Nevada School of Medicine, Reno, USA.
Newcomb LF, et al. Long-term outcomes in patients using protocol-directed active surveillance for prostate cancer. JAMA 2024 May 30; e-pub (https://doi. org/10.1001/jama.2024.6695).
This summary is taken from the following Journal Watch titles: General Medicine, Oncology and Hematology, Ambulatory Medicine.