Is active surveillance safe for men with family history of prostate cancer?

Having a family history of prostate cancer doesn’t make it more risky for men with a new diagnosis of the disease to initially hold off on active treatment in favour of monitoring with periodic lab tests, a research review suggests.

It’s becoming more common for doctors to skip aggressive treatments like surgery or radiation for men with low-risk prostate tumours in favour of doing periodic tests to see if tumours grow, a practice known as active surveillance. But research to date has offered a mixed verdict on whether this approach is safe for certain men with a higher risk, including black patients and people with a family history of prostate tumours.

For the current study, researchers analysed data from six previously published studies and found that active surveillance wasn’t linked with an increased risk of prostate cancer progressing for men with a family history. One study did, however, find that family history increased the risk of cancer progression in black men.

“The current findings can help doctors reassure patients that having a family history of prostate cancer should not automatically exclude them from being considered for active surveillance, although more research needs to be done for African-American men,” said senior study author Dr. James Dupree, a urology researcher at the University of Michigan in Ann Arbor.

Most men with prostate cancer are diagnosed with low-risk tumours that haven’t spread to other parts of the body. Often, doctors and patients struggle to choose the best course of action because it's hard to tell which tumours will grow fast enough to be life-threatening and which ones might never get big enough to cause problems.

“Just because a cancer is found, it does not automatically mean it needs to get treated right away,” Dupree said by email. “In some cases, cancer should be treated, but in other cases, it may not need immediate treatment and can be managed with active surveillance.”

For example, Dupree and colleagues reviewed one study of 200 patients that didn’t detect a meaningful difference in high-risk tumours based on whether or not men had a family history. In men who did have a family history, this study also didn’t find a difference in risk based on the number of relatives with prostate cancer.

Two other studies in the review looked at biomarkers for prostate tumours, including results from prostate specific antigen (PSA) tests that are commonly used to look for these malignancies. Neither study found family history to be a meaningful predictor of aggressive prostate cancer.

In another study, family history wasn’t a good predictor of aggressive tumours for most men, but it did signal an increased risk for black men.

One limitation of the research review is that it included only six studies, the authors note in BJU International.

Still, the findings should reassure men with a family history of prostate cancer that active surveillance may be a reasonable option in some cases, said Dr Behfar Ehdaie, a urologic surgeon at Memorial Sloan Kettering Cancer Center in New York who wasn’t involved in the study.

“Screening for prostate cancer saves lives,” Ehdaie said by email. “However, the decisions after prostate cancer is detected may lead to overtreatment.”

To strike the right balance, doctors can screen men at a young age with a PSA blood test to help determine a patient’s future risk, then recommend an appropriate treatment after a man is diagnosed with prostate cancer, Ehdaie added.

“Incorporating active surveillance to treat men with low-risk prostate cancer reduces the harms of overtreatment associated with both surgery and radiation therapy,” Ehdaie said.