Examining Conversative Management in Low/Intermediate-Risk Prostate Cancer

In an interview with CancerNetwork® during the 2026 American Association for Cancer Research (AACR) Annual Meeting, Isaac Allen, MD, a research fellow in the Department of Medical Oncology of the Division of Population Health Sciences at Dana-Farber Cancer Institute, discussed research he presented at the conference on conservative management uptake among men with low-risk and favorable intermediate-risk prostate cancer.¹ Specifically, he highlighted a trend suggesting that patients who were more frail or comorbid and those with a higher neighborhood-level socioeconomic status had a greater uptake of conservative management.

Moreover, he discussed the role of healthier post-diagnosis lifestyles, which he suggested could make patients more favorable candidates for more radical interventions, a finding that did not show significance in the study but one that could warrant further study. Furthermore, he remarked upon the generalizability of the trial. Despite focusing on the Health Professionals Follow-Up Study, which encompassed a potentially more health-liberate group of current or former medical professionals, larger and more generalizable studies showed similar outcomes regarding conservative management uptake.

Finally, he highlighted other research he presented at the conference regarding the risk of lethal progression in a similar cohort of US health professionals, which showed that men who initiated management of their disease conservatively often experienced a higher rate of lethal progression.²

CancerNetwork: Could you provide a brief background and overview of the presentation that you gave at AACR?

Allen: In brief, this study included just over 2000 men who were diagnosed with either low-risk or favorable intermediate-risk prostate cancer according to the NCCN classifications. We were interested in evaluating the uptake levels of conservative management as a treatment, as well as the rates of transition from conservative management to definitive treatment, which we defined predominantly as radiation therapy or radical prostatectomy.

We found that uptake levels have markedly increased over time. This is not unique to this cohort; conservative management for lower-risk prostate cancer has become increasingly popular over the years, and the NCCN recently switched to recommending it as the optimal choice for low-risk prostate cancers. While that is unsurprising in a broader context, we also found that higher neighborhood-level socioeconomic status and older age at diagnosis were associated with greater uptake of conservative management. Conversely, we identified associations that decreased the likelihood of receiving conservative management, making patients more likely to receive definitive treatment. These results are intuitive and have been demonstrated previously regarding the aggressiveness of prostate cancer at diagnosis.

Finally, we performed an analysis of transition rates to definitive treatment among those who initially received conservative management. We found that those who were older at diagnosis were less likely to switch from conservative management to a curative intervention.

Data suggested that a healthier post-diagnostic lifestyle was associated with a higher hazard ratio (HR) for initiating curative treatment. Does this suggest that healthier patients are more likely to pursue radical options because they are better candidates for surgery or radiation, or does it reflect a higher level of health-seeking behavior and proactive monitoring?

First, I should mention that this result was not actually significant in our study. We found an indication that a healthier post-diagnostic lifestyle led to those results, but the HR was just below the level of significance; it did not quite hit that threshold. It certainly indicates there could be more to explore, and a larger study may have the power to identify that association, but we did not find a significant result here.

Were this association to be true, both explanations are [feasible]. We looked at both age and comorbidities as adjustment variables in this study. While those are not the only things that make one a better candidate for radical treatment, you would imagine they capture at least some of the driving influences of a healthier lifestyle leading to better candidacy for radical interventions. Even following that adjustment, we still found an indication of that association. This doesn’t imply it is the sole explanation. The second explanation regarding a greater level of health-seeking behavior sounds intuitive and could very well be true, but we did not have the data to evaluate that in this study. It will be a good point of exploration for future research.

Data showed that conservative management uptake increased by 16% for every standard deviation rise in neighborhood socioeconomic status. From a multidisciplinary perspective, how can we address this disparity to ensure that active surveillance is equally accessible and supported for patients in lower-resource settings?

It is extremely important to consider barriers to access in any aspect of cancer care. To the best of my knowledge, this is the first study to look at neighborhood-level socioeconomic deprivation by using an enormous number of individual variables combined into a composite variable. This helped us look at everything in tandem to see whether neighborhood-level socioeconomic status is having an effect.

We were not the first to look at this; a previous study using SEER data examined median household incomes and found a similar result.³ This indicates there is previous evidence to back up this finding and that there may indeed be a barrier to access. In terms of ways to solve this, this is a decision best left to the policymakers. I am not a policymaker myself, but I hope this study, in combination with previous large studies, might make someone take note.

As this study focused on the Health Professionals Follow-Up Study, this cohort likely possessed higher-than-average medical literacy. How do you think the overall uptake rate and the conversion rate to curative treatment might differ in a more general community urology practice vs this specialized population?

There are a few ways in which the cohort used in this study differs from a general practice urology clinic. First are the levels of health literacy. These were all men who were health professionals when they were working; that is what led to their recruitment to the cohort. They were all health professionals or ex-health professionals. On top of that, this is a more affluent cohort than is generally the case across the US, and the racial breakdown is very different; this cohort was almost entirely White.

There are several reasons why these results might not be generalizable to the wider population in theory, but in this particular case, they seem to be broadly applicable. Previous studies looking at uptake rates of conservative management in larger datasets across the US––the vast majority of whom [are not] health professionals––found comparable results. The caveat is that those studies focused on more recent years, between 2010 and 2019, whereas ours went back to 1997 and up to 2022. The results were not entirely the same, but it does indicate that these findings, even if derived from a cohort of higher health literacy and greater affluence, are still broadly consistent with the rest of the US.

With the recent integration of MRI-targeted biopsies and genomic decoders like Decipher into standard practice toward the end of your study period, was there an observable, more rapid shift in the trigger from conservative management to curative treatment?

We could not examine this directly because we did not have access to Decipher or MRIs in these data. However, we could look at this indirectly because we had access to the calendar year in which these patients were diagnosed. If we saw an extremely strong relationship between diagnosis in a later year and conservative management uptake or transition, then that would be indirect evidence that something becoming more common in those years––including the modalities mentioned––was having an effect.

We did not find that result in this study. Regarding the transition rates, it is worth noting that the analysis did not have a huge number of people in it, nor a huge number of transitions. We were limited by statistical power there. It is not that the result could not be true, but we did not find it here. Additionally, some of the things mentioned have come in more recently. Although I’d like to think this study is fairly contemporary at the later edge, it is probably not fully contemporary in terms of cohort breakdown. We had to conclude follow-up at the end of 2022, and considering how some of these modalities are so recent, it is possible that a study performed since the start of 2020 might find those results, but we did not see it in this one.

Are there any other research or presentations at the conference that you would like to highlight?

Yes. The most obvious example is that we have research in the same cohort looking at a related question. It started as one project, but we split it into 2. Our second project is about the risk of lethal progression––defined as prostate cancer death or metastasis––in the same cohort of men with low- or favorable intermediate-risk prostate cancer.

We found that the rate of lethal progression was higher in the men who initially managed their prostate cancer using conservative management. Some studies indicate the oncologic safety of active surveillance, but in this particular cohort, that did not quite seem to be the case. Now, there are all kinds of reasons why one may wish to have conservative management rather than more aggressive definitive treatment, even if you could know that receiving definitive treatment might decrease your risk of progression.

For example, if a patient were very old, they might not want radical treatment at that point. It also has quality of life implications for people of any age. But if you are looking purely from the point of view of trying to prevent death or metastasis, then, in this particular cohort, we had a phenomenon where more people were getting conservative management, but it was less safe from a progression point of view in that same group.

Is there anything else that you would like to discuss?

One very important fact is that the conservative management group in this study includes both people who were actively surveilling their cancer and people [who underwent] watchful waiting. These are 2 different treatments given for different reasons.

Active surveillance is generally given to healthier patients because the risk of progression or death is considered low enough as to not justify the adverse effects and quality of life implications that come from definitive treatment. The hope is that it won’t progress; it is frequently examined for evidence of progression, at which point you can provide definitive treatment.

Watchful waiting is different. It is given to patients who are older or sicker for the most part or at least older and sicker than those receiving active surveillance. This has implications for the study; if we could have separated watchful waiting from active surveillance and looked at the differences in the results, we would have loved to do so. We did not have the data to do that in this study. I want to make that clear… it was not entirely an active surveillance cohort. That would mean some of our results would deserve a second look compared with the studies on active surveillance that have come out in more recent years.

References

1. Allen I, Vaselkiv JB, Guard HE, et al. Uptake of conservative management, and uptake of curative-intent treatment following conservative management, in low and favorable-intermediate risk prostate cancer patients. Presented at: American Association for Cancer Research Annual Meeting 2026. April 17-22, 2026; San Diego, CA. Abstract 2346
2. Allen I, Vaselkiv JB, Guard HE, et al. Lethal progression risks of low risk and favorable-intermediate risk prostate cancer in a prospective cohort of US health professionals. Presented at: American Association for Cancer Research Annual Meeting 2026. April 17-22, 2026; San Diego, CA. Abstract 2347
3. Emile SH, Horesh N, Garoufalia Z, et al. Household income is independently associated with overall and cancer-specific survival after proctectomy for rectal cancer: A surveillance, epidemiology, and end results-based analysis. Am J Surg. 2025;242:116191. doi:10.1016/j.amjsurg.2025.116191