Use of Active Surveillance vs Definitive Treatment Among Men With Low- and Favorable Intermediate–Risk Prostate Cancer in the US Between 2010 and 2018 - Bashir Al Hussein Al Awamlh

June 7, 2023

Ruchika Talwar and Bashir Al Hussein Al Awamlh delve into contemporary trends of active surveillance versus definitive treatment in men with low-risk and favorable intermediate-risk prostate cancer. Their discourse revolves around a new article in JAMA Internal Medicine authored by Dr. Al Hussein, presenting evidence of increased adoption of active surveillance for such patients. The researchers found a substantial rise in surveillance rates for low-risk prostate cancer (from 16% to almost 60%) and favorable intermediate-risk cases (from 8% to 22%). They interpret this as a positive development, as surveillance can help avoid overtreatment. However, they also discuss the need for more substantial increases and strategies to encourage active surveillance. Dr. Talwar and Dr. Al Hussein express hope that this conversation, along with the study's publication in a broader readership journal, could drive policy changes and a further shift towards active surveillance in managing prostate cancer.


Bashir Al Hussein Al Awamlh, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

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Ruchika Talwar: Hello everyone. Welcome to UroToday's Health Policy Center of Excellence. We'll be discussing a new article published in JAMA Internal Medicine, exploring contemporary trends of active surveillance usage versus definitive treatment in men with low and favorable intermediate risk prostate cancer. I'm excited to have my good friend and colleague, Dr. Al Hussein from Vanderbilt University Medical Center, who was first author of this study on the call today. Thanks, Dr. Al Hussein for joining us.

Bashir Al Hussein: Dr. Talwar, thank you so much. It's a pleasure to have you here and have me and it's always great to see you as always.

Ruchika Talwar: Awesome. Well, let's dive right in. Give me a little bit of background on the study that you all recently had published in JAMA Internal Medicine?

Bashir Al Hussein: Yeah, absolutely. So this study, the research question was a descriptive question or a predictive as well. The study design was a cross-sectional study and what we sought to answer was, what is going on in the country in terms of active surveillance for patients with low risk and favorable intermediate risk prostate cancer? So we used data from SEER, which was released recently. It's a national representative sample. It gives us a benchmark of what's going on in the country right now. So the data looked at patients that were diagnosed with prostate cancer from 2010 to '18 and we looked at contemporary treatments in these patients and who was getting active surveillance or not. I can go in a little bit more and tell you about the results briefly and summarize it for you.

Ruchika Talwar: Yes, please.

Bashir Al Hussein: Yeah. So what we found was that the rates were increasing for men with low risk prostate cancer, the rates were up to 60%. And for favorable intermediate risk prostate cancer, which was something that we had an idea of what's going on, but no one really looked at in that broader sense. So we looked into that and we found that there's an uptake in active surveillance for these patients. And as you know and our viewers may know that this active surveillance for men with favorable risk intermediate is an option. However, it's preferred for low risk cancer and we noted that there's an uptake in surveillance and the rates went up to 22% by 2018. So these are the main findings of the study.

Ruchika Talwar: Great. Yeah. And so I'll just emphasize a couple important points that you beautifully highlighted for us. So first, the use of active surveillance did jump, like you said, to almost 60% from about 16%, is that right? 16% prior?

Bashir Al Hussein: Yes.

Ruchika Talwar: And then for favorable intermediate risk from about 8% to 22%. So that's staggering to me. When I read that, I was really pleasantly surprised. And as you alluded to, active surveillance is definitely preferred for patients with low risk disease, but I think historically there's been a lot of hesitancy to adopt an active surveillance strategy for men with favorable intermediate risk prostate cancer. So tell me a little bit about what you thought about the results when you saw that number?

Bashir Al Hussein: I think, like you said, it was a little bit surprising and that was in a pleasant way. It counter argues the other finding, which is it's great. We're happy that the numbers are going up, it certainly is showing that urologists, racial oncologists and all physicians are comfortable with treating men with surveillance. But the 60% is great, we would like that to be higher, however, for favorable intermediate risk, it was a great finding. It was pleasantly surprising. And that just shows you and tells you that there is a group, a subset of men with certain features that can be surveyed over time. So instead of labeling everyone as intermediate risk, we're able to identify those patients and safely follow them up. Particularly with recent trial findings that are showing that men with low to favorable or intermediate risk cancer are doing well compared to definitive treatment. So this is an encouraging thing.

Ruchika Talwar: Yeah, definitely. And I love the fact that the paper's published in JAMA Internal Medicine. So I'll share a little bit of my thoughts when I saw this. There's been a lot of chatter, especially in the last few months about prostate cancer trends in general. So a couple of really concerning things that we found. In the past few years, prostate cancer has been the only cancer to increase in both incidents and rates of advanced disease at diagnosis. And so there's been a lot of hypotheses about why we're seeing this concerning trend, despite the fact that one would think our diagnostics and therapeutics have only improved over time. A lot of that has been thought to be from prostate cancer screening practice changes. So you and I both know back in 2012, the USPSTF actually gave prostate cancer screening a grade D, and there was a lot of general, I would say a bit of a negative connotation in the primary care community that was associated with prostate cancer screening.

Now a lot of that stemmed from concerns regarding overtreatment. So I think the fact that you all targeted this paper in an internal medicine journal for that sort of readership is brilliant because it helps encourage our primary care colleagues to let them know we have gotten better, we're no longer overtreating cancers that don't need to be overtreated. And I think it's good that we're monitoring patients with surveillance and making sure we are appropriately treating those who need to be treated. Tell me a little bit about your thoughts on that statement that I made and also was that what you were thinking when you were targeting this sort of journal?

Bashir Al Hussein: Absolutely. I'm going to echo your sentiments. I think targeting a journal with broader readership, particularly for medicine folks is an important thing when it comes to prostate cancer as, I mean, we all know prostate cancer is one of the most common cancers and it's very impactful and it's important. And first, showing a result for everyone that we are doing a good job by watching most men with low risk cancer is encouraging and gives us a boost for our confidence and people can trust us more. In terms of screening, I agree with you, I think the numbers are worse for prostate cancer and certainly it's hard to ignore the elephant in the room, which is really the to the PSA screening.

And now we show that we are able to do a better job by surveying these men. So in turn, as more long-term data is occurring from the European studies and other simulation models showing that, hey, PSA screening is making a difference and if we over screen certain people then find out that they're low risk, we're able to safely watch them. So that does not negate the fact that we shouldn't screen those patients. So it comes into a full circle, it's hard to talk about surveillance and not talk about PSA screening. So I definitely agree with you and I think it's hopeful and I think this is on a policy level, it may actually call for clearer guidelines and better underscoring of the fact that PSA screening can be handled appropriately.

Ruchika Talwar: Yeah, exactly. And again, I'm biased, I view all things from a policy angle, which is why when I saw your article, I thought we would have a really interesting discussion here. So I'm going to push the envelope a bit and push you a bit in extrapolating your results and thinking about what we could do next. So you've shown that we're doing, for favorable intermediate risk, a great job, I would say. For low risk men, we're doing a good job, but certainly there's room for improvement. And I wonder if part of those higher numbers for favorable intermediate are driven by providers who are already pro active surveillance in the low risk population. So what we have to target is the rest of those 40% of men who are seeing urologists who may not be as likely to recommend surveillance. So what do you think we can do as a community of urologists and maybe even the broader health policy community to incentivize providers to adopt more active surveillance and strategies in these men?

Bashir Al Hussein: Yeah, I think that's the million-dollar question and I love it. So I think a reasonable goal, and I think that's echoed by the AUA and other people, would be to get to, for example, 80% for surveillance. It's hard to get up to 100% as you know, it's such a heterogeneous cancer with a lot of variation in treatment and some men may not be comfortable with opting for surveillance. However, how can we get those numbers to be higher? This is a multifactorial problem and there's been great work that has shown that there's variation in the country, variation within each practice group, variation within oncologists down the hall from each other, whether that's related to the payments, incentivization, the culture of these physicians, the culture of the patients that are being treated. All these things muddy the waters and make it more complicated.

Our job is to continue to advocate for it. Our job is to continue to use the data that's available to us, that shows us that even with low intensity monitoring, patients are doing great. So yet along with active surveillance, we can catch these cancers, we can do a good job. We have a lot of biomarkers, we have a lot of technology like MRI scanning, we can keep a close eye and watch these men and increase these numbers to the numbers that we would like them to see. So in terms of a policy perspective, I think it's hard.

You would think that rewarding and penalizing the care in terms of thinking about value-based care, that would be something that one can consider, rewarding patients who are on or physician groups who are acting on or having a CPT, for example would be a phenomenal thing. But again, it may be difficult in a sense when you have a cancer that's very heterogeneous in how it is. But I think we're pushing the envelope, we're making progress. Ultimately what we would like is to see the absolute number of patients diagnosed with low risk cancer decrease and the proportion to go up. And that is where we would like to get to. Yeah, I would love to hear your thoughts about how we can impact policy in that sense.

Ruchika Talwar: Yeah, I mean I think you bring up good points. First, the heterogeneity of this population. Even in low risk prostate cancer, not all cancers are created equally and there're certainly men who, understandably so, may be more keen on treatment. For example, very high volume Grade Group 1 men with perhaps a family history of lethal prostate cancer. Whether or not I push as hard as I want for surveillance, some of it does come down to patient preference and their treatment related anxiety, et cetera. So I hear you there. And then also there's certain cancers where we get the sense that we may be underdiagnosing them, for example, very high PSA, things like that. Because our diagnostics are still not perfect. You bring up an interesting point with the CPT code. I think that's a great incentive to be able to bill for active surveillance and give people a little bit of a boost.

There's been a lot of talk, I've had speakers come on this forum and discuss bundles, for example. You create a prostate cancer bundle and you have a pathway for active surveillance that may incentivize providers to adopt surveillance in certain situations. We'll see where things go. I mean, I'm reassured by your results and I want to again congratulate you for a great study in such a high-impact journal. And I think that it was really smart to choose this sort of forum for publication because it creates a broad audience and lets people outside of urology know that we're aware of our issues regarding overtreatment, we are trying to do better, we're publishing these sorts of analyses to measure our progress and we're committed to reducing overtreatment of prostate cancer. So if there's anything else you'd like to add, please let me know.

Bashir Al Hussein: Thank you. I think you summarized it perfectly. I think we're doing a good job, there's certainly room for improvement and I think we're aware of it and hopefully as time goes by and we continue to accrue more data, we'll show even better trends. So thank you so much for having me and it's a pleasure to be here with you.

Ruchika Talwar: Great. Thanks again, Dr. Al Hussein. And thanks for everyone who tuned in. We'll see you again at our next UroToday Health Policy Center of Excellence video.