Detroit:
Although approximately 1 in 8 men in the US will receive a prostate cancer diagnosis during their lifetime, only about 1 in 44 will succumb to the disease. Most men diagnosed with prostate cancer die from other causes, particularly those with low-risk prostate cancer that typically progresses slowly and poses no immediate threat to life.
However, until about a decade ago, most men diagnosed with low-risk prostate cancer underwent immediate surgery or radiation treatment. While these treatments can effectively cure the cancer, they also come with severe and life-altering complications such as urinary incontinence and erectile dysfunction.
As a family physician and researcher focusing on prostate cancer screening and treatment, I have observed a growing trend of men opting against immediate treatment. Instead, they are choosing a more conservative approach known as active surveillance, which involves closely monitoring the cancer and delaying treatment until signs of progression appear.
Challenges in prostate cancer screening
Prostate cancer screening remains controversial due to the potential for overdiagnosis and overtreatment of cancers that would have otherwise remained harmless if left undetected and untreated.
The screening process typically involves a blood test to measure levels of a protein called prostate-specific antigen (PSA) produced by prostate cells. Elevated PSA levels may indicate the presence of prostate cancer, but not all cases are aggressive or life-threatening. PSA levels can also be elevated due to factors other than cancer, such as an enlarged prostate gland caused by aging.
Due to widespread PSA screening in the US, over half of the prostate cancers detected through screening are low-risk. Concerns about overdiagnosis and overtreatment of low-risk cancers are the main reasons why routine screening is not recommended unless patients choose to be screened after understanding the benefits and drawbacks through discussions with their doctor.
Understanding active surveillance
Active surveillance is a safe and effective approach to managing low-risk prostate cancer. It involves limiting treatments like surgery or radiation to only those cancers that show signs of growth or increased aggressiveness. The approach includes regular checkups and tests to monitor the tumors.
It’s important to note that active surveillance differs from “watchful waiting,” which involves a less intense form of follow-up and only focuses on relieving symptoms rather than actively monitoring the cancer. Active surveillance aims to strike a balance between closely monitoring the cancer while avoiding unnecessary treatments.
All leading medical organizations recommend active surveillance as the preferred approach for men diagnosed with low-risk prostate cancer. However, the utilization of active surveillance in the US has been historically low, ranging from under 15% in 2010 to approximately 40% in 2015. The specific reasons for this underutilization are not well understood.
Identifying factors influencing treatment decisions
To better understand the factors influencing treatment decisions, my team and I conducted a survey of 1,341 white and 347 Black men newly diagnosed with low-risk prostate cancer between 2014 and 2017. The participants were recruited from cancer registries in metropolitan Detroit and the state of Georgia, regions with significant Black populations.
Overall, more than half of the men chose active surveillance, indicating a significant increase compared to a similar study conducted almost a decade ago, which found only 10% of men opting for active surveillance.
While the increased adoption of active surveillance is positive, it is still below the rates observed in many European countries, such as Sweden, where over 80% of low-risk prostate cancer patients choose active surveillance.
To determine the factors influencing patients’ decision to choose active surveillance, we directly asked them.
The strongest influencing factor was a recommendation from a urologist, with nearly 85% of patients who chose active surveillance stating that their urologist recommended it. Other factors included shared decision-making between the patient and physician and a higher level of knowledge about prostate cancer. Interestingly, participants residing in metro Detroit were more likely to choose active surveillance compared to those in Georgia.
Conversely, patients who strongly desired a cure, expected to live longer with treatment, or perceived their low-risk cancer diagnosis as more serious were less likely to opt for active surveillance. Alarmingly, almost three-quarters of patients who chose immediate treatment had unrealistic expectations of living at least five years longer with treatment compared to without, which is not supported by existing evidence.
Misperceptions, unrealistic treatment expectations, and biases can lead patients to choose unnecessarily aggressive treatment, subjecting themselves to its harmful side effects without any survival benefit and potentially experiencing regret later on.
Racial and geographic disparities
We also discovered racial and geographic disparities in the adoption of active surveillance.
On average, Black patients face a higher risk of developing and dying from prostate cancer compared to white patients. Additionally, as the data supporting the use of active surveillance has primarily been based on studies involving white men, the risks and benefits of active surveillance in Black patients are more controversial. Our study found that 51% of Black patients chose active surveillance, compared to 61% of white patients.
Significantly, Black men reported receiving fewer active surveillance recommendations from urologists and had less engagement in shared decision-making with their doctors compared to white men. However, the racial difference in active surveillance rates became insignificant after accounting for urologist recommendations, decision-making style, and other factors.
Persistent geographic differences
Patients residing in Detroit were more likely to undergo active surveillance compared to those in Georgia. This difference likely reflects the entrenched care patterns of certain urologists. Studies have shown that urologists who have been in practice for longer are less likely to recommend active surveillance to their patients.
Promoting active surveillance
Our findings are encouraging as they indicate that active surveillance has become more acceptable to both patients and urologists over the past decade. However, our results also suggest that increased physician engagement and improved patient education can further support the adoption of active surveillance.
For instance, when physicians describe low-risk prostate cancer appropriately as small or non-aggressive, coupled with a favorable prognosis, it can provide patients with a sense of relief. Patients, in turn, feel more comfortable considering active surveillance as a viable option.
On the other hand, patients with misconceptions about the seriousness of their cancer may opt for unnecessary treatment. Physicians can reassure patients that active surveillance is a safe and preferred alternative. They can also explain that aggressive treatments do not improve survival for most low-risk patients and can lead to significant long-term side effects.
Increasing shared decision-making between patients and physicians can enhance the likelihood of choosing active surveillance compared to patients who make decisions on their own.
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