In patients with clinical favorable risk of cancer, GEC testing significantly increased the use of AS.

“[T]he rate of active surveillance (AS) was 57.9% among those without the gene expression classifier (GEC – Decipher Prostate Biopsy, Oncotype DX Prostate, and Prolaris) test compared with 75.9% among those with a GEC result below the threshold and 46.2% among those with a test result above the threshold. […] On multivariable analysis, patients with favorable-risk prostate cancer who were classified as GEC low risk were more likely to be managed on AS than those without testing (odds ratio, 1.84; P=.006).”

Hu J, et al. Clinical utility of gene expression classifiers in men with newly diagnosed prostate cancer. JCO Precis Oncol 2018.

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Radical prostatectomy does not significantly reduce mortality.

“After nearly 20 years of follow-up among men with localized prostate cancer, surgery was not associated with significantly lower all-cause or prostate-cancer mortality than observation. Surgery was associated with a higher frequency of adverse events than observation but a lower frequency of treatment for disease progression, mostly for asymptomatic, local, or biochemical progression.”

Wilt TJ, Jones KM, Barry MJ, et al. Follow-up of prostatectomy versus observation for early prostate cancer. N Engl J Med 2017; 377:132-42.

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Active surveillance of prostate cancer does not increase death rate.

“At a median of 10 years, prostate-cancer–specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments.”

Hamdy FC, Donovan JL, Lane A, et al. 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016; 375:1415-24.

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Active surveillance an option for low-risk men.

“Men with favorable-risk prostate cancer should be informed of the low likelihood of harm from their diagnosis and should be encouraged to consider surveillance rather than curative intervention.”

Tosoian JJ, Mamawala M, Epstein JI, et al. Intermediate and longer-term outcomes from a prospective active-surveillance program for favorable-risk prostate cancer. J Clin Oncol 2015; 33:3379-85.

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RP associated with decreased sexual and urinary function.

“In this cohort of men with localized prostate cancer, radical prostatectomy (RP) was associated with a greater decrease in sexual function and urinary incontinence than either external beam radiation therapy (EBRT) or active surveillance after 3 years and was associated with fewer urinary irritative symptoms than active surveillance; however, no meaningful differences existed in either bowel or hormonal function beyond 12 months or in other domains of health-related quality-of-life measures.”

Barocas DA, Alvarez J, Resnick MJ, et al. Association between radiation therapy, surgery, or observation for localized prostate cancer and patient-reported outcomes after 3 years. JAMA 2017; 317(11): 1126-40.

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Patients on AS experience fewer disruptive side effects.

“Of 1141 enrolled men, 314 pursued active surveillance (AS) (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). […] Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy, external beam radiotherapy, and brachytherapy. Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy; acute worsening of urinary obstruction and irritation with external beam radiotherapy and brachytherapy; and worsened bowel symptoms with external beam radiotherapy.”

Chen RC, Basak R, Meyer AM, et al. Association between choice of radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance and patient-reported quality of life among men with localized prostate cancer. JAMA 2017; 317(11): 1141-50.

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Urinary, sexual, and bowel function and quality of life better on AS.

“The findings of the ProtecT trial have clarified the distinct effects of prostate-cancer treatments on urinary, sexual, and bowel function and condition-specific quality of life. The negative effect of prostatectomy on urinary continence and sexual function, particularly erectile function, was greatest at 6 months, and although there was some recovery, the effect was worse than in the other treatment groups over 6 years; however, prostatectomy was associated with no change in bowel function. At 6 months, the negative effect of radiotherapy with neoadjuvant androgen deprivation therapy on sexual function, particularly erectile function, was only a little less than that of prostatectomy, and bowel function, urinary voiding, and nocturia were worse in the radiotherapy group than in the other groups. However, there was then considerable recovery in the radiotherapy group for these measures, apart from more frequent bloody stools. In the active-monitoring group, sexual (including erectile) function and urinary continence and function were affected much less than in the radical-treatment groups initially but worsened gradually over time, as increasing numbers of men received radical treatments and age-related changes occurred; bowel function was unchanged.”

Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med 2016 Oct 13; 375(15):1425-37.

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Better sexual and urinary health for those in AS.

“In this study, no differences in mental health outcomes were observed, but urinary and sexual health-related quality-of-life (HRQoL) were worse for patients who underwent radical prostatectomy (RP) compared with those who underwent active surveillance (AS) for up to 3 years. These data offer support for the management of low-risk PCa with AS as a means for postponing the morbidity associated with RP without concomitant declines in mental health.”

Jeldres C, Cullen J, Hurwitz LM, et al. Prospective quality-of-life outcomes for low-risk prostate cancer: Active surveillance versus radical prostatectomy. Cancer 2015; 121:2465-73.

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Treatment outcomes affect long-term urinary, bowel & sexual function.

“[…] men treated for localized prostate cancer commonly had declines in all functional domains during 15 years of follow-up.”

Resnick MJ, Koyama T, Fan KH, et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med 2013; 368:436-45.

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Avoiding unnecessary treatments reduces associated side effects.

“Men with localized [prostate cancer] on [active surveillance] were more often sexually active than similar men who received radical therapy, especially [radical prostatectomy].”

Van den Bergh RCN, Korfage IJ, Roobol MJ, et al. Sexual function with localized prostate cancer: active surveillance vs radical therapy. BJU Int 2012; 110:1032-39.

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