Page 128 - An Evidence Review of Active Surveillance in Men With Localized Prostate Cancer

appeared to increase patients’ knowledge concerning prostate cancer and its treatments. They
were also found to help encourage more active patient involvement in the decisionmaking
process.
The authors noted several limitations in conducting their review, namely, too few high
quality trials, heterogeneous outcome measures, and that the quality of the information provided
in the DAs themselves were not assessed, which precluded determination as to whether these
DAs met the quality standards set by the International Patient Decision Aids Standards
206
Collaboration.
Summary

Only two studies specifically examined men who were enrolled in an active monitoring
protocol with triggers for curative treatments (as opposed to other non-AS observational
management strategies). 172,173 The van As study found that the free-to-total PSA ratio and T-
stage were independent predictors of time to radical treatments in patients on the protocol, while
initial PSA, PSA density, Gleason score, number of positive cores, and prostate volume were
not. 172 The Mills study found that decreased baseline anxiety and higher socioeconomic status
were both associated with a decreased probability of willingness to consent to AS randomization
(i.e., these men did not take a chance and proactively selected AS). 173
Within the remainder of the heterogeneous studies, some tentative conclusions could be
drawn concerning observational management strategies in men with prostate cancer:
• For many men, physician recommendation is an important element in helping reach a
treatment decision.
• The context in which the consultation with a urologist is made (initial consultation versus
second opinion visit) may be a factor in determining whether observational management
strategy is offered as a treatment option or not.
• The following patient and clinical variables are potentially important in increasing the
probability that a patient receives observational management strategies: increased age,
presence of comorbidities, lower Gleason score, lower tumor stage, lower diagnostic
PSA, membership in a lower risk group, and decreased baseline anxiety.
• The following patient and clinical variables are potentially important in increasing the
probability that a patient interrupts observational management strategies to seek
definitive treatments: decreased age, higher tumor stage, higher diagnostic PSA, higher
PSA velocity, membership in a higher risk group, and increased anxiety.
• Physicians may have predetermined clinical notions as to when to recommend
observational management strategies.
• For some men, opinions from family members and other influential people are important
in reaching a treatment decision.
• Avoidance of treatment side effects is an important determinant in predicting the choice
of observational management strategies.
• Prostate disease risk perceptions matter, as those who perceived prostate cancer as a more
serious disease tended to choose RP over RT or observational management strategies.
• Men who are unattached (i.e., not in a permanent relationship) may have a higher
probability of receiving observational management strategies versus active treatments.
• Men from lower socioeconomic strata or who are black (versus white) are more likely to
receive observational management strategies.

74