Active surveillance for low-risk prostate cancer: well established, yet avoided?

Prostate cancer (PC) is the most common male malignancy [1]. While the PC-related mortality is undoubtedly significant, accounting for approximately 375 000 annual deaths worldwide [2], many patients diagnosed with PC harbor low-risk disease [defined as grade group 1, prostate-specific antigen (PSA) level <10 ng/mL and T1c–T2a stage], which is associated with an indolent clinical course. A decade ago, it was estimated that low-risk PC is diagnosed in about half of men undergoing screening [3]. As many efforts aimed to reduce the number of patients ‘overdiagnosed’ with low-risk PC have been undertaken, the rates may have been trending down in the last years, as demonstrated in a recent epidemiologic study from the United States [4]. However, diagnosis of low-risk PC still represents a commonly encountered clinical scenario and in order to minimize treatment-related morbidity, contemporary guidelines strongly recommend active surveillance (AS) in those patients [5].

Management of low-risk PC patients with AS is safe and associated with minimal (<1%) long-term risk of cancer death or metastasis [6]. Along with emerging evidence, demonstrating good outcomes of patients enrolled into AS protocols, increasing popularity of this management modality was being reported in the last decade. In the United States, percentage of low-risk PC patients managed with AS increased from 14.5 to 42.1% between 2010 and 2015 [7]. The growing rates of adoption of AS protocols in low-risk PC patients is supported by reports from other countries, as well [8, 9]. Unfortunately, we lack similar data in regard to Polish patients. Nevertheless, our observations suggest that the pace of increasing popularity of AS worldwide is not followed in Poland.

Several barriers and difficulties in adoption of AS for PC patients have been described in the literature. A nationwide survey study by Kim et al. demonstrated that physician-perceived patient's reluctance to bothersome AS protocols and repeat biopsy, as well as biases of patient treatment preferences in favor of physician's own specialty treatment represented key barriers to choosing AS [10]. Ellis et al. reported that urologists' major concerns in regard to offering AS to PC patients were risk of disease underestimation with limited technology, lack of a standard evidence-based protocol, perceived probability of patient's non-adherence, patients being anxious about biopsy side-effects, and several limitations resulting from various environmental factors [11].

Improving care and clinical outcomes in patients diagnosed with low-risk PC is an important challenge to public health. In order to assess the prevalence of AS among Polish patients, as well as to provide insight into possible barriers that hinder adoption of AS in Poland, we will conduct a nation-wide survey addressed to Polish urologists in the following months. The survey will consist of multiple statements aimed to assess physician's attitude towards AS, as well as to represent the most commonly encountered concerns. We believe that the results of the planned study will be able to serve as the primary step in developing effective strategies for increasing the rates of AS among eligible low-risk PC patients in Poland.