Monitoring proves better than active treatment for low-risk prostate cancer

Men over 60 with low-risk prostate cancer could spend ten years with no active treatment, have a better sex life as a result, yet still be very unlikely to die from the disease, new research has found.

The findings come from two new studies looking at ‘active surveillance’ of prostate cancer – when the disease is closely monitored but not treated – presented at the 2021 European Association of Urology congress today.

The first uses data from Sweden’s National Prostate Cancer Register, which has information on virtually every man diagnosed with the disease in that country since 1998 – 23,649 of whom went on active surveillance.

Active surveillance was introduced between 15 and 20 years ago for men with low-risk prostate cancer, so as yet, there is no data on the risks and benefits over a longer time period. The researchers, from Uppsala University and the University of Gothenburg, devised a new statistical technique to fill this gap.

Rather than looking simply at the numbers of patients on active surveillance who died of prostate cancer, they identified how many moved on from active surveillance to other treatments, such as radiotherapy or surgery. As these treatments have been provided for many years, long-term follow up data on them already exists.

This allowed the researchers to model the likely outcomes for men on active surveillance up to 30 years from diagnosis, based on the numbers moving onto different treatments. They were able to show not only the percentage of men who would die from the disease over that period, but also the number of years they would spend without treatment, post diagnosis.

Eugenio Ventimiglia, a urologist at San Raffaele Hospital in Milan (Italy) and a PhD student at the Department of Surgical Sciences, Uppsala University (Sweden) explained: “We wanted to identify the real winners from active surveillance, the men who are unlikely to die from their prostate cancer but who will also spend most of their remaining years without treatment if the disease is carefully monitored.

“Obviously, the older you are and the lower risk your cancer, the greater the benefit. But we saw a real divide at age 60. Men diagnosed under 60 on active surveillance have a greater likelihood of dying of prostate cancer with very little added benefit, in terms of extra years with no other treatment. After sixty, if your cancer is low-risk, then active surveillance is really a win-win: the model showed men having ten years or more without other treatment with only a low percentage likely to die from the disease.”

Low impact on sexual function

Other treatments for prostate cancer – such as radiotherapy or surgery – can result in incontinence and erectile dysfunction, whereas the physical side effects of active surveillance are minimal. Other research being presented at EAU21 today found that men on active surveillance report fewer problems with sexual function than those on other treatments.

The research draws on data from the EUPROMS study (Europa Uomo Patient Reported Outcome Study), the first prostate cancer quality of life survey conducted by patients for patients. Just under 3,000 men from 24 European countries diagnosed with prostate cancer have completed the survey at home in their own time. This allows them more time to consider their answers and report how they really feel, compared to questionnaires carried out in a clinical environment.

The survey showed that under 45 percent of men on active surveillance reported problems having an erection, compared to between 70 and 90 percent of men on other treatments.

Lionne Venderbos, Postdoctoral Researcher at Erasmus MC, Rotterdam, who analysed the survey results said: “Lack of sexual function affects patients’ quality of life more than any other reported side effect. The survey shows that active surveillance has the least impact on sexual function of all possible treatment options.

“This is important for men diagnosed with prostate cancer to be aware of, before they decide which treatment option to pursue. Men who choose active surveillance as their preferred option have the same survival rates over five years as those who chose surgery or radiation, but can also maintain sexual function.”

Hendrik Van Poppel, Emeritus Professor of Urology at Katholieke Universiteit Leuven, Belgium, and member of the EAU Executive, said: “When men diagnosed with prostate cancer are deciding their treatment option, quality of life is often the most important factor. As these studies show, active surveillance has the least negative impact, but that treatment option is only possible when the disease is diagnosed at an early stage. It’s vital to pick up this disease early, and the option of active surveillance should encourage men to overcome their reluctance to be tested for prostate cancer. Prostate cancer can be fatal, but also the later the diagnosis, the more severe the treatments and the greater the impact on quality of life.”