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Man awaiting prostate cancer results

NIHR Signal Factors in men’s choice of active surveillance for low-risk prostate cancer

Published on 7 August 2018

doi: 10.3310/signal-000630

Many personal, organisational and national factors can help or hinder men from choosing active surveillance over radical treatment when they have low-risk prostate cancer. Men are more likely to adhere to this plan of regular monitoring if they and their families are fully informed and understand that it includes the option of further treatment if necessary.

The recent ProtecT trial demonstrated that there was no difference in 10-year survival rates between men with low risk localised prostate cancer who were allocated to active surveillance and those who chose radical treatment. This is important because radical treatment carries the risk of side effects, such as incontinence and erectile dysfunction.

However, patient uptake of and adherence to active surveillance is generally low in clinical practice. This research suggests that efforts by clinicians to explain the choices available might help improve understanding, uptake or adherence. This will aid patients in making more informed decisions, potentially lessening the side effects experienced by some men.

Share your views on the research.

Why was this study needed?

Prostate cancer is the most common form of cancer for men in the UK. Around 1 in 8 will be diagnosed at some point in their life, and the prognosis for those diagnosed can be very good.

Treatment options depend upon which stage the cancer is at and risk of spreading. Many low-risk prostate cancers grow only slowly and are unlikely to cause any trouble, as confirmed in the NIHR ProtecT study. Half to two-thirds of men diagnosed with low risk localised prostate cancer will not need treatment. Therefore, a policy of monitoring, known as active surveillance, is recommended. Unlike watchful waiting, active surveillance involves planned monitoring (such as regular blood tests or biopsies) and the option of treatment if required.

Not all eligible men opt for this method, instead choosing more radical treatments, such as radiotherapy or surgery, which can have side effects. This review sought to synthesise studies of the barriers and facilitators to using active surveillance.

What did this study do?

This was a large mixed methods review of 64 qualitative and observational studies. It drew on experiences of men in high-income countries and the average age at diagnosis was 65 years, so some aspects are potentially applicable to the UK, though some may be dependent on the health system and local guidelines.

Results could not be combined in a meta-analysis due to differing study designs. These included surveys, qualitative interviews, focus groups, registry and cohort studies. The review was well conducted and summarises the available information from the last 10 years on the topic.

What did it find?

  • Family, friends and support groups play a key role in supporting men and influencing their decisions. Men feel that they have to justify their choice to their supporters, for whom ‘no treatment’ might be difficult to understand. Men's awareness of the options, and family education and reassurance about active surveillance, are linked with their ability to choose and adhere to this route.
  • Men with less advanced cancer, lower PSA levels and Gleason scores, are more likely to choose and adhere to active surveillance than opt for treatment.
  • Younger men (under 65) and those with a family history of prostate cancer are less likely to choose active surveillance.
  • The clinician’s attitude, and how they communicated information about men’s options, could be either barriers or facilitators. For example, a good relationship with the clinician and receiving information from more than one member of the team makes choosing active surveillance more likely. Some clinicians do not offer the option of active surveillance at all.
  • In non-UK countries, the existence and uptake of national guidance by healthcare organisations were linked with increased percentages of eligible patients using active surveillance.

What does current guidance say on this issue?

NICE 2014 guidance recommends active surveillance or radical treatments for men with localised prostate cancer at low to intermediate risk of progression.

NICE states that active surveillance involves an MRI scan followed by PSA tests every 3 to 4 months for the first year and then a repeat biopsy, followed by PSA tests every 3 to 6 months for the next two years, then every six months. Radical treatments are recommended for men with localised prostate cancer at high risk of progression.

Options include radical prostatectomy, external radiotherapy with hormone therapy or brachytherapy (insertion of radioactive implants into the prostate).

What are the implications?

Men with low-risk prostate cancer are influenced by several factors when choosing disease management strategies. They need more consistent information and help and support to choose and adhere to active surveillance where it is appropriate. For example, local policies and education could ensure active surveillance is taken up by more eligible men.

Perceptions also need to change as misconceptions about active surveillance are common. 

Researchers suggest that improved clinician education, patient information and psychosocial support are required if active surveillance is to be seen and promoted as a valid and safe option.

Citation and Funding

Kinsella N, Stattin P, Cahill D, et al. Factors influencing men’s choice of and adherence to active surveillance for low-risk prostate cancer: a mixed method systematic review. Eur Urol. 2018; March 26. doi: 10.1016/j.eururo.2018.02.026.

Part funded by a Cancer Center Support Grant from the National Cancer Centre Institute made to Memorial Sloan Kettering Cancer Center (P30-CA008748) a SPORE grant from the National Cancer Institute (P50-CA092629), a grant from the National Cancer Institute as part of the Cancer Intervention and Surveillance Modeling Network (U01CA199338-02) and the David H. Koch prostate cancer research fund.

Bibliography

Donovan J, Hamdy F, Lane JA, et al; ProtecT Study Group. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Eng J Med. 2016.375:1425-37.

Hamdy FC, Donovan JL, Lane JA, et al; ProtecT Study Group. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375(15):1415-24.

Martin RM, Donovan JL, Turner EL, et al; CAP Trial Group. Effect of a low-intensity PSA-based screening intervention on prostate cancer mortality: the CAP randomized clinical trial. JAMA. 2018;319(9):883-95.

NICE. Prostate cancer: diagnosis and management. CG175. London: National Institute for Health and Care Excellence; 2014.

Prostate Cancer UK. About prostate cancer. London: Prostate Cancer UK; 2016.

Public Health England. Prostate cancer risk management programme (PCRMP): benefits and risks of PSA testing. London: Public Health England; 2016.

Why was this study needed?

Prostate cancer is the most common form of cancer for men in the UK. Around 1 in 8 will be diagnosed at some point in their life, and the prognosis for those diagnosed can be very good.

Treatment options depend upon which stage the cancer is at and risk of spreading. Many low-risk prostate cancers grow only slowly and are unlikely to cause any trouble, as confirmed in the NIHR ProtecT study. Half to two-thirds of men diagnosed with low risk localised prostate cancer will not need treatment. Therefore, a policy of monitoring, known as active surveillance, is recommended. Unlike watchful waiting, active surveillance involves planned monitoring (such as regular blood tests or biopsies) and the option of treatment if required.

Not all eligible men opt for this method, instead choosing more radical treatments, such as radiotherapy or surgery, which can have side effects. This review sought to synthesise studies of the barriers and facilitators to using active surveillance.

What did this study do?

This was a large mixed methods review of 64 qualitative and observational studies. It drew on experiences of men in high-income countries and the average age at diagnosis was 65 years, so some aspects are potentially applicable to the UK, though some may be dependent on the health system and local guidelines.

Results could not be combined in a meta-analysis due to differing study designs. These included surveys, qualitative interviews, focus groups, registry and cohort studies. The review was well conducted and summarises the available information from the last 10 years on the topic.

What did it find?

  • Family, friends and support groups play a key role in supporting men and influencing their decisions. Men feel that they have to justify their choice to their supporters, for whom ‘no treatment’ might be difficult to understand. Men's awareness of the options, and family education and reassurance about active surveillance, are linked with their ability to choose and adhere to this route.
  • Men with less advanced cancer, lower PSA levels and Gleason scores, are more likely to choose and adhere to active surveillance than opt for treatment.
  • Younger men (under 65) and those with a family history of prostate cancer are less likely to choose active surveillance.
  • The clinician’s attitude, and how they communicated information about men’s options, could be either barriers or facilitators. For example, a good relationship with the clinician and receiving information from more than one member of the team makes choosing active surveillance more likely. Some clinicians do not offer the option of active surveillance at all.
  • In non-UK countries, the existence and uptake of national guidance by healthcare organisations were linked with increased percentages of eligible patients using active surveillance.

What does current guidance say on this issue?

NICE 2014 guidance recommends active surveillance or radical treatments for men with localised prostate cancer at low to intermediate risk of progression.

NICE states that active surveillance involves an MRI scan followed by PSA tests every 3 to 4 months for the first year and then a repeat biopsy, followed by PSA tests every 3 to 6 months for the next two years, then every six months. Radical treatments are recommended for men with localised prostate cancer at high risk of progression.

Options include radical prostatectomy, external radiotherapy with hormone therapy or brachytherapy (insertion of radioactive implants into the prostate).

What are the implications?

Men with low-risk prostate cancer are influenced by several factors when choosing disease management strategies. They need more consistent information and help and support to choose and adhere to active surveillance where it is appropriate. For example, local policies and education could ensure active surveillance is taken up by more eligible men.

Perceptions also need to change as misconceptions about active surveillance are common. 

Researchers suggest that improved clinician education, patient information and psychosocial support are required if active surveillance is to be seen and promoted as a valid and safe option.

Citation and Funding

Kinsella N, Stattin P, Cahill D, et al. Factors influencing men’s choice of and adherence to active surveillance for low-risk prostate cancer: a mixed method systematic review. Eur Urol. 2018; March 26. doi: 10.1016/j.eururo.2018.02.026.

Part funded by a Cancer Center Support Grant from the National Cancer Centre Institute made to Memorial Sloan Kettering Cancer Center (P30-CA008748) a SPORE grant from the National Cancer Institute (P50-CA092629), a grant from the National Cancer Institute as part of the Cancer Intervention and Surveillance Modeling Network (U01CA199338-02) and the David H. Koch prostate cancer research fund.

Bibliography

Donovan J, Hamdy F, Lane JA, et al; ProtecT Study Group. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Eng J Med. 2016.375:1425-37.

Hamdy FC, Donovan JL, Lane JA, et al; ProtecT Study Group. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375(15):1415-24.

Martin RM, Donovan JL, Turner EL, et al; CAP Trial Group. Effect of a low-intensity PSA-based screening intervention on prostate cancer mortality: the CAP randomized clinical trial. JAMA. 2018;319(9):883-95.

NICE. Prostate cancer: diagnosis and management. CG175. London: National Institute for Health and Care Excellence; 2014.

Prostate Cancer UK. About prostate cancer. London: Prostate Cancer UK; 2016.

Public Health England. Prostate cancer risk management programme (PCRMP): benefits and risks of PSA testing. London: Public Health England; 2016.

Factors Influencing Men's Choice of and Adherence to Active Surveillance for Low-risk Prostate Cancer: A Mixed-method Systematic Review

Published on 31 March 2018

Kinsella, N.,Stattin, P.,Cahill, D.,Brown, C.,Bill-Axelson, A.,Bratt, O.,Carlsson, S.,Van Hemelrijck, M.

Eur Urol , 2018

CONTEXT: Despite support for active surveillance (AS) as a first treatment choice for men with low-risk prostate cancer (PC), this strategy is largely underutilised. OBJECTIVE: To systematically review barriers and facilitators to selecting and adhering to AS for low-risk PC. EVIDENCE ACQUISITION: We searched PsychINFO, PubMed, Medline 2000-now, Embase, CINAHL, and Cochrane Central databases between 2002 and 2017 using the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The Purpose, Respondents, Explanation, Findings and Significance (PREFS) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) quality criteria were applied. Forty-seven studies were identified. EVIDENCE SYNTHESIS: Key themes emerged as factors influencing both choice and adherence to AS: (1) patient and tumour factors (age, comorbidities, knowledge, education, socioeconomic status, family history, grade, tumour volume, and fear of progression/side effects); (2) family and social support; (3) provider (speciality, communication, and attitudes); (4) healthcare organisation (geography and type of practice); and (5) health policy (guidelines, year, and awareness). CONCLUSIONS: Many factors influence men's choice and adherence to AS on multiple levels. It is important to learn from the experience of other chronic health conditions as well as from institutions/countries that are making significant headway in appropriately recruiting men to AS protocols, through standardised patient information, clinician education, and nationally agreed guidelines, to ultimately decrease heterogeneity in AS practice. PATIENT SUMMARY: We reviewed the scientific literature for factors affecting men's choice and adherence to active surveillance (AS) for low-risk prostate cancer. Our findings suggest that the use of AS could be increased by addressing a variety of factors such as information, psychosocial support, clinician education, and standardised guidelines.

The Gleason score is a measure of the likelihood of cancer cell growth and spread outside the prostate gland. 10 represents the most aggressive cancers which are most likely to grow and spread.

Expert commentary

PSA testing identifies many men with low-risk disease for whom radical treatment represents overtreatment. This coupled with the recent negative CAP trial of PSA screening strengthens the UK National Screening Committee’s advice not to screen for prostate cancer. 

However, PSA testing will continue in symptomatic patients, and the ProtecT study, which shows that active surveillance for screen-detected prostate cancer is associated with similar mortality rates as radical treatment, makes this systematic review timely and relevant.

Implementation of good information, psychosocial support, education of clinicians and clear guidelines should enhance the reputation and uptake of appropriate active surveillance.

Robert J C Steele, Senior Research Professor, University of Dundee