Active surveillance of low-grade prostate cancer alternative to overtreatment

For men with low-grade prostate cancer, active surveillance - monitoring with the option to treat if the cancer worsens - is the most common management strategy at a regional diagnostic centre in Ottawa, Ontario, according to new research in CMAJ (Canadian Medical Association Journal).

"These findings represent a substantial paradigm shift in the management of low-grade prostate cancer and may represent an important reduction in the potential harm associated with overtreatment of screening-detected cancers," writes Dr. Rodney Breau, a surgical oncologist at The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, with coauthors.

Active surveillance combines close monitoring with periodic prostate-specific antigen (PSA) measurements, digital rectal exams and biopsies. If the cancer worsens, the physician will discuss appropriate treatments with the patient.

Low-grade prostate cancer makes up between 40% and 50% of all newly diagnosed cancers. Patients with these cancers are at low risk of cancer-related death but may experience adverse effects of treatment. Active surveillance is an approach for which treatment may be delayed or completely avoided. Screening for prostate cancer is controversial, with some groups recommending against screening because of the substantial risk of over-detection and over-treatment. There are few data detailing the use of active surveillance in clinical practice.

The study included 477 men with low-grade cancer referred to the Ottawa Regional Prostate Cancer Assessment Clinic between 2008 and 2013. Of those, 210 (44%) were managed with active surveillance and 244 (51%) were treated immediately for prostate cancer. The authors observed an increase in the use of active surveillance from 32% in 2008 to 67% in 2013. Patients who were older than 70 and who had multiple health issues were more likely to receive active surveillance than younger men. Of the patients managed with active surveillance, 62 (30%) were eventually treated because of a change in their disease status.

After five years of follow-up, about 59% of patients were still being managed by active surveillance.

"Our results reinforce the concept that patient preference or anxiety does not appear to be the major factor driving progression to treatment. In the Canadian context, it seems that active surveillance is a feasible management approach that patients and physicians are willing to accept," state the authors.

CMAJ published prostate cancer screening guidelines http://www.cmaj.ca/content/ 186/16/1225 from the Canadian Task for on Preventive Health Care in late 2014.

Public health should be involved in Canada's national inquiry into missing and murdered aboriginal women, because many factors underlying family and interpersonal violence are linked to mental health issues, substance abuse, low income and other public health issues, urges an editorial in CMAJ (Canadian Medical Association Journal).

"It's clear that a common web - woven of a legacy of colonization and cultural genocide, and a cumulative history of societal neglect, discrimination and injustice - underlies both endemic interpersonal violence and health disparities in Canada's indigenous populations," states Dr. Kirsten Patrick, deputy editor, CMAJ. "There is no conversation to be had about one without a conversation about the other - if the aim is healing - because the root causes are the same."

With the public health sector actively trying to address disparities in social disparities of health in many parts of the country, it can also make an important contribution in the upcoming inquiry.
"We are presented with not just an opportunity for renewing trust between indigenous communities and the Government of Canada but also for extending the roles of public health and the health care sector in the facilitation of health and healing," concludes Dr. Patrick.

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