Prostate

Comment from Henk van der Poel: Do we give impartial advice? Or who is unbiased? Early analyses showed a preferential treatment advice dependent on the main treatment modality provided by a specific physician. Urologist were more likely to provide prostatectomy, whereas radiation oncologist preferentially used radiotherapy and men consulting a medical oncologist were more likely to receive an initial active surveillance management of low and intermediate risk prostate cancer.  In a large cohort of patients (12.000) with low risk prostate cancer diagnosed over the age of 65 year treatment was analyzed. The majority of men (80%) with low risk disease received treatment. Men seen by urologists only, a urologist with more years after training and urologists that treat non-low-risk prostate cancer were all significantly more likely to undergo treatment as opposed to an (active) surveillance approach. In men visiting the radiation oncologist upfront treatment was even higher than for urologists: over 90%. Between 2006 and 2009 an  increasing rate of observation was noted (from 17.5% to 25.1%) indicating that the field is continuously shifting and data from 8 years ago may and should not affect nowadays decision-making on the topic of active surveillance. With an increase in life-expectancy data from the SPCG-4 trial, in some cases even before the PSA era should be interpreted with caution. Although active surveillance adaptation will continue to improve, with longer follow up the “progression” rate leading to active treatment in men initially managed conservatively is shown to exceed 50%. Finally, although urologists seem to advice active treatment in many men with low risk prostate cancer, they don’t stand alone. Also radiation oncologists tend to shy away form active surveillance and perform active treatment in over 90% over referred men with low risk prostate cancer.