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.

Image-based monitoring of targeted biopsy-proven prostate cancer on active surveillance: 11-year experience

“…The surveillance prostate biopsy has been regarded as useful evaluation tool for AS. However, the sampling error of surveillance biopsy is well documented in many AS studies [18][19][20]. Berglund et al [18] found upgrading in 27 % of the patients undergoing immediate restaging biopsy.…”

“…Berglund et al [18] found upgrading in 27 % of the patients undergoing immediate restaging biopsy. Eggener et al [19] found a 30 % rate of upgrading on restaging biopsy before initiation of surveillance-based treatment. van den Bergh et al also reported that a 22 % of upgrading with re-biopsy at 1 year in a large cohort of more than 500 men undergoing active surveillance.…”

Urinary Incontinence, Patient Satisfaction, and Decisional Regret after Prostate Cancer Treatment: A French National Study

“…The incidence in Northern and Western Europe is the highest in the European Union, and rates in Eastern and Southern Europe are steadily increasing [3]. The management of localized prostate cancer is challenging for urologists in terms of both treatment costs and risk of over-diagnosis, which can lead to over-treatment and secondary complications that outweigh the potential benefits [4]. …”

Prognostic influence of 5 alpha reductase inhibitors in patients with localized prostate cancer under active surveillance

“…In final pathology reported Gleason sum was ≥7, while positive surgical margin rate was 8%, extrapostatic extension rate was 15%, and positive lymph node rate was 4%. [12] In the Johns Hopkins series which had a very strict on patient selection criteria, lymph node positivity rate was 2.1% (2/96). [13] In the current study lymph node metastasis was detected following RP only in one patient with a Gleason sum of 9.…”

“…In a study, "rebiopsy within the first 3 months" was included in the inclusion criteria to confirm tumor histopathology. [12] In another study by Berglund et al[ 14] on the issue, rebiopsies were performed in 104 patients scheduled for AS at median 6 months after initial biopsy. Increase in grade and/or stage of the tumor was 27% (28/104), and these patients were excluded from the AS protocol.…”