Page 38 - Encyclopedia of Nursing Research

ACTivE SURvEiLLANCE FoR PRoSTATE CANCER n 5

active surveillance, this management strat- of 150 Dutch men during their first 9 months
egy remains underutilized by men in the of active surveillance. However, Bailey et al.
United States as fewer than 10% of poten- (2009) reported that men between 5 and 8 A
tially appropriate patients select this option months of active surveillance experienced
(Large & Eggener, 2009). moderate levels of illness uncertainty. in
Active surveillance has evolved from the a previous study, men with higher levels
concept of watchful waiting, a strategy of of illness uncertainty had lower levels of
periodic monitoring followed by active treat- quality of life (Hegarty, Wallace, & Comber,
ment if and when disease progression leads 2008). Quality of life may also be affected by
to troublesome symptoms (Adolfsson, 1995). the cost of care associated with a diagno-
Historically, watchful waiting was viewed as sis of prostate cancer (Gomella, Johannes, &
a strategy for men in their seventies, with con- Trabulsi, 2009). However, this relationship
comitant illnesses that prohibited traditional has not been confirmed.
therapy. However, many patients and health in contemporary practice, patient selec-
care providers viewed this as a do-nothing tion remains a significant challenge because
approach, and few considered it a reasonable we still do not have the ability to accu-
strategy for disease management resulting in rately determine at the time of diagnosis
low rate of adoption (approximately 5%) by which patients’ disease will remain indo-
men in the United States; this may contrib- lent. However, several clinicians and can-
ute to the low numbers of men currently in cer centers have proposed selection criteria.
active surveillance. in addition, health care Warlick, Allaf, and Carter (2006) has refined
providers may be reluctant to offer this strat- the identification process to include men who
egy because they are uncertain about how to are 65 years and older with T1c stage disease,
appropriately manage patients, fear of legal PSA density less than 0.15 ng/ml/cm , and
3
backlash in the event a patient’s disease pro- a Gleason grade of 6 or less after adequate
gresses to an advanced stage or dies, and a biopsy as the safest candidates for active
strongly held belief that cancer should be surveillance followed by active treatment.
fought with the best treatments available. Clinicians at the University of California, San
From an economic perspective, the adop- Francisco, have established criteria for men
tion of active surveillance for early stage pros- with low-risk prostate cancer as the best can-
tate cancer has the potential to reduce costs, didates for active surveillance. These criteria
to impact psychosocial outcomes, and to include Gleason sum of 6 (no tumor grade
affect quality of life. in an evaluation of cost pattern of 4 or 5), PSA at diagnosis of 10 ng/ml
associated with the diagnosis of prostate can- or less and stable, 33% or less positive cores,
cer, Crawford, Blac, Eaddy, and Kruep (2010) and 50% or less single-needle core involved
determined that the total cost of monitoring with cancer from biopsy, stable repeat PSA,
a man’s disease to be $24,809 compared with and organ-confined disease determined by
$59,286 for treatment that mostly included ultrasound. This center has enrolled more
surgical intervention to remove the prostate than 500 men into an active surveillance
cancer. The direct cost of treating prostate protocol. To date, approximately one in five
cancer with any type of traditional therapy of those men have undergone treatment for
was five times higher than a course of careful their disease an average of two to three years
monitoring (Crawford et al., 2010). The find- after diagnosis (Dall’Era et al., 2008).
ings are mixed with regard to the impact a The National Comprehensive Cancer
course of active surveillance has on psycho- Network (2010) has recently updated their
social outcomes and quality of life. van den guidelines to recommend only active surveil-
Bergh et al. (2010) reported favorably low lance for men diagnosed with low-risk pros-
levels of anxiety and depression in a sample tate cancer who have a life expectancy of less