Platinum Priority – Review – Prostate CancerEditorial by Chris H. Bangma, Riccardo Valdagni, Peter R. Carroll, Hein van Poppel, Laurence Klotz and Jonas Hugosson on pp. 646–648 of this issueHow Does Active Surveillance for Prostate Cancer Affect Quality of Life? A Systematic Review
Introduction
The incidence of prostate cancer (PCa) worldwide is increasing as opportunistic screening becomes more widespread and average life expectancy rises [1]. A large randomised controlled trial showed disease-specific mortality benefits to population-based PCa screening in Europe [2], [3] with less clear results in a similar trial in the United States [4], possibly due to the high rates of prostate-specific antigen (PSA) testing in their control group. However, both overdiagnosis and resulting overtreatment are problematic sequelae of PCa screening, due to the low diagnostic specificity of PSA levels and prostatic biopsies.
Active surveillance (AS) is an option for patients with favourable risk, localised PCa; AS aims to avoid or delay radical treatments without compromising long-term, disease-specific survival. AS involves regular monitoring by multimode imaging, PSA levels, and prostatic biopsies [5], [6], [7]. AS has existed for around 15 yr worldwide, although uptake has generally been modest outside established research cohorts such as the Prostate Cancer International Active Surveillance (PRIAS) study [8]. However, recent prominence of AS in American and European PCa management guidelines will potentially further increase use of this approach [9].
Radical treatment can have lifelong impact on patients’ quality of life (QoL), including erectile, rectal, and urinary dysfunction [10]. Patients undergoing AS can potentially avoid these consequences of radical treatment but may suffer negative psychological effects due to living with an untreated cancer and the fear of disease progression [11], [12], [13]. If AS patients experience heightened distress and anxiety, they are potentially more likely to opt for radical treatment in advance of protocol-based recommendations [14].
The need to understand the potential psychological burden of AS was identified during an international AS conference in February 2014 in Amsterdam. This systematic review aimed to evaluate the published evidence on the health-related quality of life (HRQoL) and its related psychological dimensions in men undergoing AS, to help inform clinical practice and treatment decision making. Previous literature reviews in this area were nonsystematic [13], [14], [15], combined HRQoL studies of AS patients and of those undergoing passive observation without radical intervention (watchful waiting [WW]) for patients unsuitable for radical treatment [12], or were focused on the clinical outcomes of AS [5].
Section snippets
Evidence acquisition
This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [16] with predefined search terms, inclusion and exclusion criteria, data collection, and analysis processes.
Evidence synthesis
The literature search identified 1157 unique citations (Fig. 1); 1087 citations were excluded as they were reviews, commentaries, abstracts, validation of questionnaires, or participants were on WW. Three citations were identified by searches of bibliographies, thus leaving 73 citations for a full-text screening. Of these, 63 citations were excluded. Major reasons for exclusion were that patients did not meet eligibility criteria for AS (n = 27), no mental QoL data were reported (n = 9), papers
Conclusions
Controversy exists around the nature and extent of the burden of living with untreated PCa for AS patients. This systematic review, based on around 1000 AS patients in 10 studies, indicated no major perturbations to their HRQoL and psychological well-being in the first few years. These findings are, to our knowledge, from the first systematic review to focus entirely on the HRQoL of AS patients. Limitations of the review included a potential self-selection bias, as no studies were randomised,
References (50)
- et al.
Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012
Eur J Cancer
(2013) - et al.
Mortality results from the Goteborg randomised population-based prostate-cancer screening trial
Lancet Oncol
(2010) - et al.
Active surveillance for prostate cancer: a systematic review of the literature
Eur Urol
(2012) - et al.
Active surveillance for low-risk prostate cancer worldwide: the PRIAS study
Eur Urol
(2013) - et al.
EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent—update 2013
Eur Urol
(2014) Active surveillance: towards a new paradigm in the management of early prostate cancer
Lancet Oncol
(2004)- et al.
Predictors of health-related quality of life and adjustment to prostate cancer during active surveillance
Eur Urol
(2013) - et al.
Lifestyle and health-related quality of life of men with prostate cancer managed with active surveillance
Urology
(2006) - et al.
Does active surveillance lead to increased distress and anxiety in partners of prostate cancer patients? Data of the Swiss ERSPC-center
J Urol
(2012) - et al.
Do anxiety and distress increase during active surveillance for low risk prostate cancer?
J Urol
(2010)
Measuring quality of life in men with prostate cancer using the functional assessment of cancer therapy-prostate instrument
Urology
Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale
Gen Hosp Psychiatry
Assessing anxiety in men with prostate cancer: further data on the reliability and validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC)
Psychosomatics
Prostate cancer diagnosis: the impact on patients’ mental health
Eur J Cancer
Active monitoring, radical prostatectomy, or radiotherapy for localised prostate cancer: study design and diagnostic and baseline results of the ProtecT randomised phase 3 trial
Lancet Oncol
Screening and prostate-cancer mortality in a randomized European study
N Engl J Med
Mortality results from a randomized prostate-cancer screening trial
N Engl J Med
Active surveillance for clinically localized prostate cancer—a systematic review
J Surg Oncol
Active surveillance for the management of prostate cancer in a contemporary cohort
Cancer
Quality of life after radical prostatectomy or watchful waiting
N Engl J Med
The relationship between anxiety and time to treatment for patients with prostate cancer on surveillance
J Urol
The role of anxiety in prostate carcinoma: a structured review of the literature
Cancer
Psychological aspects of active surveillance
Curr Opin Urol
Psychosocial aspects of active surveillance
Curr Opin Urol
Living with untreated prostate cancer: predictors of quality of life
Curr Opin Urol
Cited by (98)
Diet and Health-related Quality of Life Among Men on Active Surveillance for Early-stage Prostate Cancer: The Men's Eating and Living Study (Cancer and Leukemia Group 70807 [Alliance])
2022, European Urology FocusCitation Excerpt :They met well-defined and widely accepted clinical criteria for active surveillance, represented a broad swath of geographically diverse academic and community practices in the USA, and included a relatively large (12%) sample of Black/African-American patients [11]. These results confirm that appropriately selected patients who have chosen active surveillance express minimal anxiety and depression about prostate cancer [8,10,29,30]. They do not align with prior observations of cancer-associated anxiety driving treatment decisions [4–6].
Using Competing Risk of Mortality to Inform the Transition from Prostate Cancer Active Surveillance to Watchful Waiting
2022, European Urology FocusCitation Excerpt :Older men and those with significant comorbidities who have shorter LE and a low chance of PCa-specific mortality may benefit more from watchful waiting (WW), which involves PSA testing and more limited follow-up, with further evaluation only if symptoms develop or PSA values rise dramatically [7–9]. WW avoids potential morbidity and cost associated with AS interval prostate biopsies, MRI, and associated stress and anxiety that may negatively impact quality of life without adding appreciable benefit [10]. In recent years, AS enrollment has expanded greatly [11].
A Narrative Overview of Active Surveillance for Clinically Localised Prostate Cancer
2020, Seminars in Oncology Nursing
- †
Contributed equally.