For men with borderline risk factors, the multiparametric MRI can help determine who would be appropriate for conservative treatment and who should proceed to radiation, surgery or hormone therapy in conjunction with the Prolaris, Oncotype DX or Decipher tests. Genomic analysis can also help patients and physicians determine the most appropriate path for disease management.
The improvement in testing is “analogous to the changes in prostate biopsy, where we’ve gone from six on the right and left to targeted biopsy,” Loeb said. “We’re seeing the same advancement in treatment of prostate cancer as the science evolves and we discover more about genetics and pathways in prostate cancer development. There’s been an overall trend toward more precision in diagnostics and treatment.”
For men with higher-risk disease, “hopefully in the future we can offer many more targeted approaches so that individuals with different mutations involved in their cancer will received different treatment,” Loeb said.
For many men, though, doing nothing, at least not right away, remains the best course.
The VA leads the country in adoption of guideline-concordant care in the treatment of localized, low-risk prostate cancer, defined as prostate-specific antigen less than 10 ng/mL, Gleason score of six or less, and Stage T2a or lower.
Today, conservative management is the “dominant strategy among veterans,” Loeb told U.S. Medicine, with more than 70% of younger men and nearly 80% of veterans over age 65 choosing to defer treatment in 2015.2
Those numbers compare favorably to the adoption of active surveillance nationally, which reached 42% in 2015, according to a recent study in JAMA.3
That’s not too surprising, given the VA’s long-standing involvement in defining and evaluating conservative management.
“Many men will die with, not of, prostate cancer,” said Bruce Montgomery, MD, co-leader of the Prostate Cancer Foundation-VA precision medicine initiative, medical oncologist at the VA Puget Sound and clinical director of genitourinary medical oncology at the Seattle Cancer Care Alliance. “VA participation was a big component of the studies on active surveillance that defined what are the indicators to go on to therapy and how men tolerate active surveillance.”
Conservative management does not necessarily mean a decision to not treat prostate cancer, but it does reduce the risks associated with overtreatment in men with indolent disease. Adverse effects from treatment include high rates of incontinence and erectile dysfunction as well as bowel complications, osteoporosis, diabetes, cardiovascular disease and cardiovascular death.
“It includes watchful waiting, which has no curative intent and no careful follow-up protocol, but has as a primary goal preserving quality of life. We only treat these patients if their disease progresses to symptoms,” Loeb said.
For many men with low-risk prostate cancer, watchful waiting will be all they need. Only 1% to 3% of men in this category will develop metastatic disease or die from prostate cancer within 15 years, even without treatment.
“Active surveillance is at the other end of the conservative management spectrum,” Loeb said. “We test frequently to closely monitor cancer, so that curative intent can be offered at the earliest moment.”
Bloom JB, Hale GR, Gold SA, et al. Is It Safe to Avoid Biopsy in Men with Elevated PSA? Prostate Cancer Advisor. January 9, 2018.
Loeb S, Byrne N, Makarov DV, Lepor H, Walter D. Use of Conservative Management for Low-Risk Prostate Cancer in the Veterans Affairs Integrated Health Care System From 2005-2015. JAMA. 2018 Jun 5;319(21):2231-2233. doi: 10.1001/jama.2018.5616. PubMed PMID: 29800017.
Mahal BA, Butler S, Franco I, et al. Use of Active Surveillance or Watchful Waiting for Low-Risk prostate Cancer and Management Trends Across Risk Groups in the United States, 2010-2015. JAMA. Feb. 11, 2019;321(7):704-706.