Two steps forward, one step back: When health news overlooks active surveillance as treatment for prostate cancer

Kathlyn Stone is an associate editor with She tweets as @KatKStone.

Men with newly diagnosed prostate cancer deserve to be informed of all treatment possibilities–including less-aggressive options such as active surveillance. But it’s not unusual to see news stories and PR efforts overlook the latter as an evidence-based choice.

For example, a story in the New York Times last week highlighted the experience of a man who had undergone short-course radiation to treat his prostate cancer.

“After learning he had early stage prostate cancer, Paul Kolnik knew he wanted that cancer destroyed immediately and with as little disruption as possible to his busy life as the New York City Ballet’s photographer.”

The story goes on to describe the growing popularity of a treatment known as “short-course stereotactic body radiation therapy” (SBRT), stating the number of men getting SBRT “doubled to 1,886 in 2013 from 716 in 2007” while standard radiation therapy for prostate cancer declined over the same time period, according to Medicare data.

The article does a lot well–it provides context about side effects, includes insights from many oncology experts, and describes the existing gaps in research: “One reason for the dearth of data is that prostate cancer usually grows slowly, if at all, so it can take many years to see if a treatment saved lives. It is expensive and difficult to follow patients for such a long time, and the treatments given to the men often change over a decade, making doctors wonder if the results are relevant.”

What’s involved in active surveillance?

But the story didn’t include a treatment option known as active surveillance. This option is sometimes recommended for men with the most common type of prostate cancer, that is, slow growing and at low risk of developing into an aggressive cancer. It involves regular prostate-specific antigen, or PSA, blood tests and digital rectal exams once or twice a year and a biopsy every 1 to 2 years. Each of the tests are to gauge any changes that would point to the need for more aggressive treatment. In most cases, prostate cancer won’t show much (or any) change over 10 years.

This omission of active surveillance as an option for early-state prostate cancer is one we also called out in a recent review of a news release from the American Society for Radiation Oncology (ASTRO) about high-dose radiation.

Reviewers wrote: “A concern with this study is that nearly all of the patient volunteers would have been candidates for active surveillance–meaning that they did not need an active treatment. With no caveat that expert guidelines recommend surveillance for low-risk Stage 1 prostate cancers, this release engages in disease-mongering.”

Emphasizing new, “advanced” approaches to treatment at the expense of lower-risk, cheaper options is something we commonly see in news stories and PR efforts relating to health care. It’s a prime example of why our expert reviewers always ask “Does the story compare the new approach with existing alternatives?” when they evaluate stories and news releases.

Active surveillance in recent medical research

Meanwhile, there’s a growing body of research showing that patients and their doctors should discuss active surveillance as a viable option.

Just last week, two new studies came out in JAMA looking at quality of life in patients treated with surgery (radical prostatectomy), radiation or surveillance. One 3-year study by researchers at Vanderbilt University, found that men undergoing surgery and radiation experienced worse sexual dysfunction at three months than those in the surveillance group. They also observed that surgery was associated with a worsening of sexual function and urinary incontinence than either radiation or active surveillance at 3 years, but with fewer urinary irritations than those choosing active surveillance. ( applied its systematic criteria in a review of Vanderbilt’s news release on the study. Reviewers noted it did many things well but erred in leaving out specifics on the measured benefits.)

The researchers concluded that the findings could help patients and physicians weigh comparative harms from each therapy, which would aid them in making the best treatment choice. The other study by researchers at the University of North Carolina at Chapel Hill had similar outcomes.

Last year, there was the clinical trial known as PIVOT (Prostate Intervention vs Observation Trial), which we wrote about. We were pleased to see the New York Times describing how many men diagnosed with prostate cancer “are opting for active surveillance of their cancer rather than more aggressive surgery or radiation.” That option deserved at least a line of acknowledgment in the Times’ most recent story about radiation.

‘Our society says if you can treat something, you treat it’

Shared decision-making on choosing a treatment for early stage prostate cancer is what led health care journalist Howard Wolinsky to choose active surveillance for managing his prostate cancer. Wolinsky, along with urologist Chris Warlick, MD, talk about the surveillance option in our podcast published earlier this month.

Wolinsky, now in his seventh year of active surveillance treatment, said choosing the option was not easy, and he saw more than one urologist.

“Our society says if you can treat something, you treat it. You know, ‘out, out damn cancer.'” But in choosing active surveillance Wolinsky says “you’re proactive by doing nothing. It’s not necessarily an easy thing to do.”

It may not be an easy choice, but it’s a choice that more men deserve to know about.

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