Active Surveillance for Incidental (cT1a/b) Prostate Cancer: Long-Term Outcomes of the Prospective Noninterventional HAROW Study

Abstract

<b><i>Introduction:</i></b> Optimal treatment for incidental prostate cancer (IPC) after surgical treatment for benign prostate obstruction is still debatable. We report on long-term outcomes of IPC patients managed with active surveillance (AS) in a German multicenter study. <b><i>Methods:</i></b> HAROW (2008–2013) was designed as a noninterventional, prospective, health-service research study for patients with localized prostate cancer (≤cT2), including patients with IPC (cT1a/b). A follow-up examination of all patients treated with AS was carried out. Overall, cancer-specific, and metastasis-free survival and discontinuation rates were determined. <b><i>Results:</i></b> Of 210 IPC patients, 68 opted for AS and were available for evaluation. Fifty-four patients had cT1a category and 14 cT1b category. Median follow-up was 7.7 years (IQR: 5.7–9.1). Eight patients died of which 6 were still under AS or watchful waiting (WW). No PCa-specific death could be observed. One patient developed metastasis. Twenty-three patients (33.8%) discontinued AS changing to invasive treatment: 12 chose radical prostatectomy, 7 radiotherapy, and 4 hormonal treatment. Another 19 patients switched to WW. The Kaplan-Meier estimated 10-year overall, cancer-specific, metastasis-free, and intervention-free survival was 83.8% (95% CI: 72.2–95.3), 100%, 98.4% (95% CI: 95.3–99.9), and 61.0% (95% CI: 47.7–74.3), respectively. In multivariable analysis, age (RR: 0.97; <i>p</i> < 0.001), PSA density ≥0.2 ng/mL<sup>2</sup> (RR: 13.23; <i>p</i> < 0.001), and PSA ≥1.0 ng/mL after surgery (RR: 5.19; <i>p</i> = 0.016) were significantly predictive for receiving an invasive treatment. <b><i>Conclusion:</i></b> In comparison with other AS series with a general low-risk prostate cancer population, our study confirmed the promising survival outcomes for IPC patients, whereas discontinuation rates seem to be lower for IPC. Thus, IPC patients at low risk of progression may be good candidates for AS.

Two Decades of Active Surveillance for Prostate Cancer in a Single-Center Cohort: Favorable Outcomes after Transurethral Resection of the Prostate

“…First, a majority of the landmark studies on AS report data on those who received prostate biopsies (T1c) in response to elevated PSAs or pathological DREs [ 7 , 22 ], but few, if any, studies have addressed the differences in disease progression between T1a/b and T1c tumors. This is all despite the fact that the incidence of incidentally found PCa is relatively high, at between 8 and 15% [ 23 , 24 , 25 ]…”

Detection rate and variables associated with incidental prostate cancer by holmium laser enucleation of the prostate

“…Magistro et al demonstrated that these two factors were not associated with IPCa after HoLEP in 1125 patients who underwent HoLEP. 3 The role of PSA and PSA density to predict IPCa after HoLEP can be controversial.…”

“…2 So we often experience cases that cannot be diagnosed with prostate cancer, suspecting them having prostate cancer from biochemical and imaging findings. The prognosis of IPCa, which pathological stage is T1a or T1b, is relatively good, 3 but additional surgery or radiation therapy is sometimes required, affecting the patient's quality of life. 4 Therefore, it is crucial to identify the detection rate and risk factors of IPCa by BPH surgery.…”

Incidental Prostate Cancer: A Real Need for Expansion in Guidelines?

“…Although the level of evidence is limited, the literature suggests that very low prostate-specific antigen (PSA) after BPO surgery (mainly <1 ng/ml), very low PSA density (PSAd) after BPO surgery (0.03 ng/ml/cm 3 ), and the absence of suspicious lesions on multiparametric magnetic resonance imaging (mpMRI) are predictors of the absence of residual tumor [6,7]. If not performed before BPO surgery, mpMRI might be useful for detection of residual suspicious lesions and trigger targeted biopsy to rule out residual csPCa [8].…”

“…Patients with favorable prognostic factors (initial PSA <10 ng/ml, low PSA and low PSAd after surgery) and only ISUP grade 1 cancer in the resected tissue can be considered at low risk [6]. AS or watchful waiting should be offered on the basis of the individual's life expectancy.…”