Active surveillance for the management of prostate cancer in a contemporary cohort

Abstract

BACKGROUND.Active surveillance followed by selective treatment for men who have evidence of disease progression may be an option for select patients with early‐stage prostate cancer. In this article, the authors report their experience in a contemporary cohort of men with prostate cancer who were managed with active surveillance.METHODS.All men who were managed initially with active surveillance were identified through the authors' institutional database. Selection criteria for active surveillance included: prostate‐specific antigen (PSA) <10 ng/mL, biopsy Gleason sum ≤6 with no pattern 4 or 5, cancer involvement of <33% of biopsy cores, and clinical stage T1/T2a tumor. Patients were followed with PSA measurements and digital rectal examination every 3 to 6 months and with transrectal ultrasound at 6‐ to 12‐month intervals. Beginning in 2003, patients also underwent repeat prostate biopsy at 12 to 24 months. The primary outcome measured was active treatment. Evidence of disease progression, defined as an increase in rebiopsy Gleason sum or significant PSA velocity changes (>0.75 ng/mL per year), was a secondary outcome. Chi‐square and log‐rank tests were used to compare groups. The association between clinical characteristics and receipt of active treatment was analyzed by using Cox proportional hazards regression.RESULTS.Three hundred twenty‐one men (mean age [±standard deviation]: 63.4 ± 8.5 years) selected active surveillance as their initial management. The overall median follow‐up was 3.6 years (range, 1–17 years). The initial mean PSA level was 6.5 ± 3.9 ng/mL. One hundred twenty men (37%) met at least 1 criterion for progression. Overall, 38% of men had higher grade on repeat biopsy, and 26% of men had a PSA velocity >0.75 ng/mL per year. Seventy‐eight men (24%) received secondary treatment at a median 3 years (range, 1–17 years) after diagnosis. Approximately 13% of patients with no disease progression elected to obtain treatment. PSA density at diagnosis and rise in Gleason score on repeat biopsy were associated significantly with receipt of secondary treatment. The disease‐specific survival rate was 100%.CONCLUSIONS.Selected individuals with early‐stage prostate cancer may be candidates for active surveillance. Specific criteria can be and need to be developed to select the most appropriate individuals for this form of management and to monitor disease progression. A small attrition rate can be expected because of men who are unable or unwilling to tolerate surveillance. Cancer 2008. © 2008 American Cancer Society.

Pathological Findings and Prostate Specific Antigen Outcomes After Radical Prostatectomy in Men Eligible for Active Surveillance—Does the Risk of Misclassification Vary According to Biopsy Criteria?

“…The number of positive cores, the tumour length (total or at any core) and the percent of cancer involvement at any core are predictive factors of tumour volume in RP specimens or biochemical failure after RP [8,[22][23]. The aim of our retrospective study was to compare the rate of misclassification associated with the use of 3 different biopsy criteria [13, [16][17]. For each criterion, we also tested the impact of PSA density on the number of men eligible and the risk of unfavourable disease [van den Bergh, Carter].…”

“…This may represent a bias, the target population for AS being larger than our restricted cohort. In this study, we tested current AS criteria which were internationally used or recently published [Carter,13,[16][17][18]. Our listing of AS criteria was not complete but provided a representative cohort of the men actually included in AS protocols.…”

“…Other characteristics to consider include pathological biopsy parameters with a wide variation concerning the AS inclusion criteria. A cancer involvement of <33% of biopsy cores was retained in the UCSF cohort [16]. Other series included cancers involving <3 cores only [14] and with an extent of cancer in any core <50% [13,17].…”

Active Surveillance for Low-Risk Prostate Cancer

“…The distinction is particularly important in that neither oncologic, nor quality of life, outcomes from patients assigned to observation in older randomized trials, [8,14], nor those identified in population-based registries as receiving conservative management, can be considered representative of those expected with contemporary active surveillance. Table 1 summarizes the published prospective experience with active surveillance, comprising more than 2900 patients [15][16][17][18][19][20][21][22][23]. These studies differ in terms of their eligibility and triggers for intervention.…”

Advances and future directions in management of prostate cancer

“…Previously referred to as "Watchful Waiting," this option has become structured with regular protocols including repeat prostatic biopsy and routine follow-up visits. Clearly this is not the best option for all patients, but recent data suggests that in a highly selected group of patients, active surveillance could provide a safe alternative to radical local therapy [8,9]. Caveats of this option include psychological distress, poor compliance, and possibly missing the window during which a cancer could be curable.…”