Page 27 - An Evidence Review of Active Surveillance in Men With Localized Prostate Cancer

of many of the examined studies were either treatment with an observational strategy or
interruption (cessation) of the observational strategy. Studies generally did not directly analyze
the offer or acceptance of or adherence to AS.

Primary Care
One survey of New Zealand general practitioners found that 45 percent would offer
observational management if the patient’s life expectancy was <10 years, but only 3 percent
would offer observational management to patients with a longer life expectancy. Five surveys of
patients reported that their physician’s treatment recommendation was the most influential factor
in deciding on their treatment. In one survey, 81 percent of men on observational management
who ultimately received active treatment believed that the treatment was favored by their
physicians; in contrast, only 24 percent of the physicians’ notes documented that the physician
recommended treatment.

Diagnosing Physician
One survey of patients on observational management strategies reported that observational
management strategies were offered by 36 percent of the physicians who had made the initial
diagnosis.

Consultant—Second Opinion

One survey was of men diagnosed with early-stage cancer. They had not yet decided on
treatment and were recommended by their urologists to seek a second opinion. None of the men
followed through with the recommendation to seek a second opinion, but the offer reinforced
their trust and confidence in their urologists. A survey of Australian men who had a urological
consultation reported that 71 percent of the urologists discussed observational management
strategies, compared with 92 percent who discussed RP and 87 percent RT. One survey of
urologists regarding men with localized cancer and few comorbidities found that 4 percent
preferred observational management strategies; two-thirds preferred RP. The same study
reported that 20 percent of patients thought that treatment options were not discussed, while only
1 percent of the urologists thought so. In a survey of men and their urologists, the urologists, in
an initial consultation setting, recommended observational management strategies to 25 percent
of men and offered 0.5 more treatment options than the urologists in a second opinion visit
setting, who recommended observational management strategies to only 16 percent of men.

Clinical Factors

One survey of urologists and radiation oncologists reported that about 10 to 20 percent would
recommend observational management strategies for a 65 year old man with a low PSA, a
Gleason score of 4 or 5, in good health, with negative DRE, and no evidence of nonlocalized
disease. Almost none would recommend observational management strategies for those with
higher PSA or Gleason scores. The responses of urologists and radiation oncologists did not
differ significantly. Numerous multivariable analyses found that receipt of observational
management strategies was predicted by older age, an increased number of comorbidities, lower
Gleason score, well-differentiated tumor, lower stage disease, lower PSA, or low-risk on the
D’Amico scale. Multivariable analyses also found that interruption of observational management
strategies was predicted by higher stage disease, higher PSA at diagnosis, decreased free-to-total

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