A Multi-Institutional Evaluation of Active Surveillance for Low Risk Prostate Cancer

Abstract

Purpose-For select men with low-risk prostate cancer, active surveillance (AS) is more often being considered a management strategy. In a multicenter retrospective study we evaluated the actuarial rates and predictors of remaining on AS, incidence of cancer progression, and pathologic findings of delayed radical prostatectomy.Methods-A cohort of 262 men from four institutions met the following inclusion criteria: age ≤75, PSA ≤10 ng/ml, clinical stage T1-T2a, biopsy Gleason sum ≤6, ≤3 positive cores at diagnostic biopsy, a repeat biopsy before AS, and no treatment for six months following the repeat biopsy. AS started on the date of the second biopsy. Actuarial rates of remaining on AS were calculated and univariate Cox regression used to assess predictors of discontinuing AS.Results-With a median follow-up of 29 months 43 patients ultimately received active treatment. The two and five-year probabilities of remaining on AS were 91% and 75%, respectively. Patients with cancer on the second biopsy (HR=2.23; 95% CI: 1.23-4.06; p=0.007) and a higher number of cancerous cores from the two biopsies combined (p=0.002) were more likely to undergo treatment. Age, PSA, clinical stage, prostate volume, and number of total biopsy cores sampled were not predictive of outcome. One patient developed skeletal metastases 38 months after starting AS. Of the 43 patients undergoing delayed treatment, 41 (95%) are without disease progression at a median of 23 months following treatment.Conclusions-With a median follow-up of 29 months, AS for select patients appears to be safe and associated with a low risk of systemic progression. Cancer at restaging biopsy and a higher total number of cancerous cores are associated with a lower likelihood of remaining on AS. A restaging biopsy should be strongly considered to finalize eligibility for AS.

Active surveillance in localized prostate cancer: comparison of incidental tumours (T1a/b) and tumours diagnosed by core needle biopsy (T1c/T2a): results from the HAROW study

“…This is consistent with data from Europe [20] and the USA [22]: in these studies, the distribution to RP, RT, HT and 'other' therapies was 48.0, 45.2, 1.5 and 5.3%, respectively, and 60.5, 30, 7 and 2.5%, respectively. By contrast, Klotz et al [28] found the use of RT was predominant at 67% (RP, 26%; HT, 7%).…”

“…Most clinical studies mention T1c and T2a tumours almost exclusively. T1a/b cancer is either not included in the reports, not specified separately or represented only sparingly [20][21][22], e.g. 4.8% in the report by Klotz et al [8].…”

Extended Followup and Risk Factors for Disease Reclassification in a Large Active Surveillance Cohort for Localized Prostate Cancer

“…10,11,19,24 Fewer cohorts reportedly have a median followup of beyond 5 years. 5e7 Our results extend the median followup previously reported in this cohort from 3.6 to 5 years and include more than 200 men with followup beyond 7.5 years.…”

Prostate cancer collaborative stage data items—their definitions, quality, usage, and clinical implications: A review of SEER data for 2004‐2010

“…27 Along with clinical TNM stage and preoperative PSA value, Gleason score based on biopsy is among the most important factors in treatment decision making for prostate cancer. 13,[17][18][19][20] The AJCC 6th and 7th editions both state that prostate cancers should be microscopically diagnosed. Therefore, theoretically nearly every case should have Gleason patterns (SSF7) and/or scores (SSF8) recorded.…”

“…24 Several studies have explored the value of using the number of positive biopsy cores to enhance prediction of clinically insignificant disease or recurrence, with mixed results. 13,30 Inclusion of the number of positive and negative cores enhanced the predictive accuracy of a preoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy. 31 The AJCC 7th edition recommended as clinically significant collecting both the number of cores positive for cancer (SSF12) and the number of cores examined (SSF13).…”