Editorial Comment to Current use of active surveillance for localized prostate cancer: A nationwide survey in Japan

Active surveillance (AS) is now firmly established as the preferred management strategy for many men with low-risk prostate cancer. Even in the USA where AS has traditionally been underutilized, urologists have now started to embrace AS,1 while in Australia, AS is used as the primary management strategy for 37% of men with low-risk disease and 8.9% of men with intermediate-risk disease.2 For low-risk disease, several large AS studies3 show this to be a safe and feasible management option with mature data showing 10- and 15-year actuarial cause-specific survival rates of 98.1% and 94.3%, respectively.4 At 5- and 10-year follow up, 75.7% and 63.5% remain intervention-free, thereby avoiding the undoubted morbidity of surgery or radiotherapy. All of the major guidelines have now endorsed this strategy, which certainly goes some way to addressing the issue of overtreatment in the screen-detected population of patients who have emerged with the widespread use of prostate-specific antigen testing in recent years. What then are we to make of this interesting pattern of care paper published in the International Journal of Urology this month?5 In this large survey of 863 training hospitals in Japan, of which a quite representative 632 (73.2%) responded (including 2133 urologists), we get the first real sense of the use of AS in Japan and of the attitudes of Japanese urologists towards AS. There are a few interesting observations. First, it seems remarkable that over one-quarter (26.2%) of urologists had “no use for AS,” despite the convincing evidence and guideline recommendations for the safety of AS for low-risk disease. While accepting that most published studies are in non-Japanese populations, this high rate of disapproval of AS does seem to represent a remarkably negative view of AS in general. Second, the lack of standardization in the use of AS protocols is noteworthy, especially as the majority of respondents do not routinely use repeat prostate biopsies as part of the follow up for men on AS. Overall, 40.1% of respondents carried out repeat biopsy at 1 year (in line with published protocols), but 24.1% “did not usually” carry out repeat biopsy and 31.8% carried it out “only when they considered it necessary.” Of those who did use a standardized protocol, the Prostate Cancer Research International: Active Surveillance (PRIAS study) protocol was most frequently used. Magnetic resonance imaging scanning was used in up to 90% of respondents at the time of initiation of AS, and it was noted that older urologists were less likely to use AS. It was also remarked by the authors that some respondents did not discriminate between AS and watchful waiting when presented with a case of an older patient with multiple comorbidities. This study provides an interesting contemporary overview of AS in Japan. It is encouraging that knowledge and use of AS is high in many centers, but there also is some negativity and variability in how AS is being practiced. It would be helpful to see protocols (such as Prostate Cancer Research International: Active Surveillance or the Multiple Japan AS Study) being more widely encouraged. None declared.

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