Oliver Sartor, MD, on Active Surveillance for Prostate Cancer in African American Men

Oliver Sartor, MD, Professor of Medicine at Tulane School of Medicine and Medical Director of the Tulane Cancer Center, discusses his recent study, published in Urology, on the safety and efficacy of active surveillance for prostate cancer in African American men.

Urban Health Today: Can you give a brief overview of your study in Urology on active surveillance in African American men and the results?

Oliver Sartor, MD: One of the things that we know is that active surveillance is preferred by many men. And it turns out, that it’s appropriate for many men with low-risk prostate cancer. So this study was performed at the VA hospital, a population that I think everyone here on the call will be familiar with. And it looked prospectively as a database for men who were African-American and men who were Caucasian. And then prospectively following them over a three-year period to determine what the outcomes might be. And the bottom line is that whether you were white or Black, it really didn’t make a lot of difference in terms of our study and in terms of the rates of progression. Both men progressed in about a 40% rate on to something other than active surveillance. But there was no differences between the Caucasians and African-Americans.

Other studies have seemingly indicated that African-Americans may be more prone to progression and maybe less appropriate for active surveillance. I think the importance of this study is that there’s no indication that that’s the case. And that we feel, on the basis of this study and additional data, that active surveillance is appropriate within a low-risk prostate cancer population of men who are appropriately compliant with follow-up and who are willing and able to participate in our protocols. So that is a little bit of a caveat because if you have a patient who’s not going to be compliant with your protocols, then I don’t think that active surveillance is really appropriate. But if you’ve got a compliant and appropriate population, then I think that active surveillance is just fine for African-American men. And that’s an important message.

Urban Health Today: What are the benefits and risks of the active surveillance strategy for prostate cancer?

Oliver Sartor, MD: Well, I think active surveillance is a very appropriate strategy for low response to cancer. And that’s typically defined as a Gleason 6 cancer with a PSA of less than 10 and a digital rectal staging that is either 21C or T2A. Within that subgroup of men, there’s never really been a trial to show that in PSA detected men, that there’s an advantage for treatment over no treatment. The obvious advantage is you avoid the side effects of treatment. And if you look at active surveillance as a strategy, the sexual side effects of surgery or radiation or hormonal deprivation, are diminished rather considerably. And then of course, you have the issues that relate to cancer controls.

It turns out that treating men with Gleason 6 cancer, you’re going to control the cancer 99% of the time if you intervene, but it’s just not necessary, because these patients typically don’t progress at a significant rate. So putting them on active surveillance, watching them closely and then intervening in a selective fashion, for those that do have progression, well, I think it’s a real advantage and very little disadvantage.

Potential disadvantages are that you miss a cancer that is going to progress. And then instead of undergoing curative therapy, you try to treat the patient for cure, and you don’t have success. Well, it turns out that that is an occasional problem, but it’s pretty rare. And most men, when properly counseled, are willing to undergo that risk in exchange for the benefit of avoiding surgery or radiation that can alter either sexual or urinary function.

Urban Health Today: African American men are more likely to have more advanced prostate cancer. Why is active surveillance is an important topic for this patient population?

Oliver Sartor, MD: There’s a lot of data to show that African-American men may be less likely to undergo therapy, even when therapy is needed. And it turns out, that I think personally, that some of those issues relate to both sexual and urinary dysfunction that comes with therapy. If you have a good risk stratification system and can watch the men who have a low-risk cancer safely and avoid therapy, I think that can be very appealing. Now, the thing that is critical is to ensure that if people need to move on to active therapy, that they receive it in a timely fashion.

At times, some of the people that are on surveillance are just avoiding active therapy. And that’s something you have to be careful about. Now, what I’m going to say is true for both African-American men, as well as men of other ethics persuasions. But what I’ll say is that African-American men do fear therapy for reasons related to urinary and sexual dysfunction. And to be able to offer active surveillance to a group that has fear of therapy, I think is particularly important.