PCRI's Open Letter to NCCN Regarding 2021 Designation Change of Active Surveillance for Low-Risk Prostate Cancer
Dear Dr. Schaeffer and fellow NCCN Prostate Cancer Guideline Panelists,
The Prostate Cancer Research Institute and its medical advisory board are deeply concerned about the recent removal of the “preferred” designation of Active Surveillance (AS) in individuals with low-risk prostate cancer.
We strongly urge the restoration of the “preferred” status for AS. We also recommend greater emphasis on the value of imaging, assays, and AS protocol compliance to minimize the small risks of AS and reduce the greater risk of unnecessary overtreatment with radical therapies. Stronger emphasis on these factors would ultimately spare many men from life-altering consequences. (See The US Preventive Services Task Force, May 2018 recommendation). The NCCN has been agnostic on imaging and assays despite strong evidence that these tools improve patient safety. The NCCN should emphasize imaging and diagnostic assays as accessibility is likely to expand with growing demand.
NCCN Guidelines are routinely used around the world to guide decision-making. For this reason, a seemingly insignificant change in verbiage will have profound implications. By using equivocal language, the NCCN invites providers to recommend radical treatment when it is not needed. This change in designation would induce warrantless anxiety in patients that will lead to more unnecessary treatment. Virtually all physicians specializing in genitourinary cancers, including Dr. Schaeffer yourself, have a consensus that AS is the prima facie approach in men with low-risk disease. In the US, utilization of AS in men with low-risk prostate cancer is still just over 50%. As such, efforts must be made to ensure the public’s awareness of AS’s safety.
We would also like to address that if this change in designation is based on unique concerns for the African-American (AA) community, we believe this change would do far more harm than good. The insinuation that AS may not be as safe for low-risk black men or that radical treatment is equally viable is not supported by evidence. The 2020 retrospective study “Association Between African American Race and Clinical Outcomes in Men Treated for Low-Risk Prostate Cancer With Active Surveillance” and the 2019 prospective study “African American Race is Not Associated with Risk of Reclassification during Active Surveillance: Results from the Canary Prostate Cancer Active Surveillance Study” have provided strong evidence that AS is as safe for AA men as it is for anyone else when there is similar management.
The best solution is to be unequivocal in the value of diagnostic tools, push for their use and emphasize the importance of complete compliance with AS protocols. Considering the growing body of evidence supporting the safety of Active Surveillance in low-risk men and the expanding accessibility to technologies that further improve its safety, it is our position that removal of “preferred” status from AS implies an equivalence with radical treatment that is not supported by evidence and will further exacerbate overtreatment and detriment to quality-of-life. We urge the NCCN to reconsider this change.
We make this request as part of an informal coalition of advocacy groups, including Active Surveillance Patients International, Prostate Cancer International, UsToo, Zero - The End of Prostate Cancer, Answer Cancer, and likely more to follow.
Sincerely,
Alex Scholz
CEO, PCRI