Discussion

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  Cite this guideline

Prostate Cancer Foundation of Australia and Cancer Council Australia PSA Testing Guidelines Expert Advisory Panel. Clinical practice guidelines PSA Testing and Early Management of Test-Detected Prostate Cancer. Sydney: Cancer Council Australia. [Version URL: http://wiki.cancer.org.au/australiawiki/index.php?oldid=122838, cited 2017 Nov 22]. Available from: http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/Active_surveillance/Discussion.

National Health and Medical Research Council These guidelines (recommendations) in the web-version of this guideline were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 2 November 2015 under section 14A of the National Health and Medical Research Council Act 1992. expand arrow

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In approving the guidelines (recommendations), NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of five years. NHMRC is satisfied that the guidelines (recommendations) are systematically derived, based on the identification and synthesis of the best available scientific evidence, and developed for health professionals practising in an Australian health care setting.

This publication reflects the views of the authors and not necessarily the views of the Australian Government.

Chapter 4 Active surveillance

Discussion

Unresolved issues

There are several unresolved issues about identifying men in whom active surveillance is likely to achieve the optimal balance of benefits and harms. These include:

  • difficulty in estimating life expectancy
  • the safety of active surveillance in men diagnosed with Gleason score 7 (3 + 4) cancer
  • the role of multiparametric MRI in selecting men for active surveillance
  • the role of new biomarkers including genomic and epigenetic panels in selecting men for active surveillance
  • the safety of active surveillance in men younger than 60 years.

There are also several unresolved issues about patient monitoring while on active surveillance and triggers for intervention. These include:

  • the frequency of PSA measurement and repeat biopsy while on active surveillance
  • the role of multiparametric MRI in predicting prostate cancer progression, which might affect the way care is organised and have resource implications
  • the role of PSA doubling time as a trigger for intervention, given the multiple non-malignant causes of a variable and rising PSA levels
  • the potential role of new genomic and epigenetic markers in selecting men for continued active surveillance. To date, the use of such indicators remains experimental and is not considered standard of care.
  • quality-of-life outcomes of different active surveillance protocols.

Studies currently underway

Several randomised controlled trials are currently underway which, when published, may help identify appropriate criteria for active surveillance. These include:

  • ‘Evaluation of Four Treatment Modalities in Prostate Cancer With Low or Early Intermediate Risk’ (PREFERE) trial[1] (Germany)
  • ‘Prostate Testing for Cancer and Treatment’ (ProtecT) trial[2][3] (UK)
  • The ‘MRIAS’ Study: Prospective, multi-centre, observational cohort study of multi-parametric MRI in active surveillance for low risk Prostate Cancer (Australia).

Other recent studies may inform guidance for managing sexual health in men with prostate cancer.[4][5]

Future research priorities

Important unresolved questions in the selection for men for active surveillance include:

  • the role of multiparametric MRI in the selection of men for active surveillance, and in their monitoring protocols
  • whether decision aids can assist men and their partners in the selection of active surveillance as their treatment of choice for low risk localised cancer
  • the significance of Gleason score 3 + 4 vs 4 + 3 cancers in selection for active surveillance
  • the role of genomics and epigenetic biomarkers in selecting and monitoring men for active surveillance
  • the psychosocial needs of men recently diagnosed with prostate cancer and starting an active surveillance protocol.

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References

  1. Stöckle M, Bussar-Maatz R. [Localised prostate cancer: the PREFERE trial]. Z Evid Fortbild Qual Gesundhwes 2012;106(5):333-5; discussion 335 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22818151.
  2. Lane JA, Hamdy FC, Martin RM, Turner EL, Neal DE, Donovan JL. Latest results from the UK trials evaluating prostate cancer screening and treatment: the CAP and ProtecT studies. Eur J Cancer 2010 Nov;46(17):3095-101 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21047592.
  3. Donovan J, Mills N, Smith M, Brindle L, Jacoby A, Peters T, et al. Quality improvement report: Improving design and conduct of randomised trials by embedding them in qualitative research: ProtecT (prostate testing for cancer and treatment) study. Commentary: presenting unbiased information to patients can be difficult. BMJ 2002 Oct 5;325(7367):766-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12364308.
  4. Chambers SK, Schover L, Halford K, Clutton S, Ferguson M, Gordon L, et al. ProsCan for Couples: randomised controlled trial of a couples-based sexuality intervention for men with localised prostate cancer who receive radical prostatectomy. BMC Cancer 2008 Aug 8;8:226 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18687149.
  5. Cormie P, Chambers SK, Newton RU, Gardiner RA, Spry N, Taaffe DR, et al. Improving sexual health in men with prostate cancer: randomised controlled trial of exercise and psychosexual therapies. BMC Cancer 2014 Mar 18;14:199 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24641777.

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