Clinical and pathologic factors predicting reclassification in active surveillance cohorts

Abstract

The incidence of small, lower risk well-differentiated prostate cancer is increasing and almost half of the patients with this diagnosis are candidates for initial conservative management in an attempt to avoid overtreatment and morbidity associated with surgery or radiation. A proportion of patients labeled as low risk, candidates for Active Surveillance (AS), harbor aggressive disease and would benefit from definitive treatment. The focus of this review is to identify clinicopathologic features that may help identify these less optimal AS candidates.A systematic Medline/PubMed Review was performed in January 2017 according to PRISMA guidelines; 83 articles were selected for full text review according to their relevance and after applying limits described.For patients meeting AS criteria including Gleason Score 6, several factors can assist in predicting those patients that are at higher risk for reclassification including higher PSA density, bilateral cancer, African American race, small prostate volume and low testosterone. Nomograms combining these features improve risk stratification.Clinical and pathologic features provide a significant amount of information for risk stratification (>70%) for patients considering active surveillance. Higher risk patient subgroups can benefit from further evaluation or consideration of treatment. Recommendations will continue to evolve as data from longer term AS cohorts matures.

A single-center long-term experience of active surveillance for prostate cancer: 15 years of follow-up

“…These results are consistent with previous RP pathology in Western AS cohorts, where the percentage of unfavorable disease and ≥T3a pathologic staging were 29% and 18.0%, respectively, in the PRIAS protocol, and 25.3% and 36.5%, respectively, in a multi-institutional European cohort [23,24]. While previous literature on AS have cited clinicopathologic factors such as number of positive cores, percent core involvement, and PSA density as predictors of increased risk of intervention [1,25,26], only maximal percentage of core involvement was significantly associated with risk of intervention in our results (HR, 1.145; 95% CI, 1.045-1.255; p=0.004), which may be due to a relatively small sample size. While ≤50% maximal percentage of single core involvement was included to reflect the most liberal enrollment criteria in reported Western cohorts [27], previous report on Korean males by Jeong et al [4] have also reported significant similar association with a hazard ratio of 1.02 (95% CI, 1.01-1.03; p<0.001).…”

Using prognosis to guide inclusion criteria, define standardised endpoints and stratify follow‐up in active surveillance for prostate cancer

“…MRI targeting has also changed the meaning of biopsy core information and it is currently unknown how this informs AS progression. Our present cohorts were small and predominantly White European men but future work in multicentre and multi‐ethnic studies can also investigate the complimentary role of family history, race, testosterone levels, and genetic factors in predicting progression . Finally, all our present cohorts’ follow‐ups were relatively short and extrapolation to longer term follow‐up awaits future studies.…”

Endogenous testosterone density as ratio of endogenous testosterone levels on prostate volume predicts tumor upgrading in low-risk prostate cancer

“…Although low-risk subjects under AS represent a highly selected cohort, disease reclassification with tumor upgrading is even a more serious drawback for the delayed active treatment of occult aggressive disease. This particular set of patients show upgrading rates that vary from 30% up to 50%, as well; a retrospective study found out that the risk of tumor upgrading was 49.3% in low-risk patients undergoing surgery when AS inclusion criteria were considered [20,21].…”