Intensity of Active Surveillance and Transition to Treatment in Men with Low-risk Prostate Cancer

Background: Active surveillance (AS) is increasingly utilized for low-risk prostate cancers, to delay or avoid treatment. Objective: To (1) describe uptake and surveillance intensity of real-world use of AS and compare with national guidelines, and (2) describe transitions from conservative to curative treatment by different indications of disease progression. Design, setting, and participants: A population-based cohort study of men diagnosed with low-risk prostate cancer, in Stockholm County, Sweden, during 2008-2017. Follow-up was up to 10 yr, with a median of 3.5 yr. Outcome measurements and statistical analysis: Poisson regression was used to estimate incidence rate ratios of prostate-specific antigen (PSA) testing and biopsies. Cox regression was used to estimate hazard ratios of starting curative treatment. Results and limitations: A total of 6021 men with low-risk prostate cancer were included in the analysis; 3116 (52%) had AS recorded as the intended primary management (AS cohort). During 1, 2, and 3 yr after diagnosis, the frequencies of at least one PSA test were 90%, 92%, and 88%, respectively, and those of postdiagnostic surveillance biopsies were 42%, 19% and 18%, respectively. During surveillance, 13% of men in the AS cohort were upgraded on rebiopsy, with Gleason upgrading being the strongest factor for starting curative treatment. One limitation is the generalizability to other populations because of differences between surveillance protocols and clinical settings. Conclusions: Our results show that AS is underutilized and that monitoring differs from current guidelines. Optimization of AS protocols is important in order to increase adherence and avoid overtreatment. Patient summary: Active surveillance has the potential to reduce overtreatment and avoid treatment-related side effects. Our results show that few men receive the recommended monitoring. (c) 2019 The Authors. Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).