Active surveillance in patients with a PSA >10 ng/mL

Abstract

Introduction: The use of prostate-specific antigen (PSA) in active surveillance (AS) for prostate cancer is controversial. Some consider it an unreliable marker and others as sufficient evidence to exclude patients from AS. We analyzed our cohort of AS patients with a PSA over 10 ng/mL. Methods: We included patients who had clinical T1c-T2a Gleason ≤6 disease, and ≤3 positive cores with ≤50% core involvement at diagnostic biopsy and ≥2 total biopsies. Patients were divided into 3 groups: (1) those with baseline PSA >10 ng/mL, (2) those with a PSA rise >10 ng/mL during follow-up; and (3) those with a PSA <10 ng/mL throughout AS. Adverse histology was defined as biopsy parameters exceeding the entry criteria limits. We further compared this cohort to a concurrent institutional cohort with equal biopsy parameters treated with immediate radical prostatectomy. Results: Our cohort included 698 patients with a median follow-up of 46.2 months. In total, 82 patients had a baseline PSA >10 ng/ mL and 157 had a PSA rise >10 ng/mL during surveillance. No difference in adverse histology incidence was detected between groups (p = 0.3). Patients with a PSA greater than 10 were older and had higher prostate volumes. Hazard ratios for groups with a PSA >10 were protective against adverse histology. Larger prostate volume and minimal core involvement appear as factors related to this successful selection of patients to be treated with AS. Conclusion: These results suggest that a strict cut-off PSA value for all AS patients is unwarranted and may result in overtreatment. Though lacking long-term data and validation, AS appears safe in select patients with a PSA >10 ng/mL and low volume Gleason 6 disease.

Metastatic Prostate Cancer in Men Initially Treated with Active Surveillance

“…Toren et al reported that surveillance patients with PSA >10 ng/ml, either at baseline or follow up, were protected against adverse histology. 22 The Hopkins group concluded that men with an elevated PSA level (10<PSA ≤20 ng/mL) and lower PSAD (<0.15 ng/mL/g) are not at higher risk of adverse surgical pathology and metastasis compared with only low-risk features. 23 Although our study didn't collect PSA density, PSA above 10 ng/ml had no impact on metastasis.…”

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for prostate cancer 2017

“…Follow-up should entitle history, physical examination, and PSA every 3–6 months and repeated biopsy every 12–18 months (at least once); radical therapy should be offered if PSA velocity >0.35 ng/ml/year or progression in any of the aforementioned criteria[ 20 21 22 23 24 ] All RPs should be done in tertiary care centers by high-volume surgeons (EL-2); surgeon experience has been associated with improved recovery of postoperative continence and erectile function, with a very low surgical mortality[ 25 26 ] Lymph node dissection (LND) can be omitted if the chance of being positive is <5% according to nomograms (EL-2)[ 27 28 ] Intensity-modulated EBRT is the minimal standard of EBRT, in which the only acceptable biological dose is ≥74 Gy (EL-2). [ 29 30 31 ] Intermediate risk – Therapy options depend on the following: If life expectancy is <5 years, a patient will have no further intervention until he becomes symptomatic or develops clinical progression (EL-2)[ 13 16 ] If life expectancy is between 5 and 10 years, options include active surveillance,[ 9 ] RP with LND as per nomograms,[ 32 ] or EBRT with 6 months of androgen deprivation therapy (ADT) (EL-2)[ 33 34 ] If life expectancy is >10 years, options are RP with LND (EL-1)[ 35 ] or EBRT with 6 months of ADT (EL-2)[ 33 34 ] High risk – Therapy options include EBRT (including pelvic lymph nodes and with or without brachytherapy boost) with ADT for 18 months[ 36 37 38 39 40 41 42 43 ] or RP with LND[ 44 45 ] Locally advanced disease (cT3-4 or N1) EBRT (including pelvic lymph nodes and with or without brachytherapy boost) with ADT for 2–3 years (EL-1)[ 46 47 48 49 ] <...>…”

Saudi oncology society and Saudi urology association combined clinical management guidelines for prostate cancer

“… If life expectancy is <5 years: Patient will have no further intervention until he becomes symptomatic or clinical progression (EL-2)[ 13 15 ] If life expectancy is between 5 and 10 years: Options include active surveillance, RP, or EBRT with 6 months of androgen deprivation therapy (ADT) (EL-2)[ 15 16 17 32 33 34 35 ] If life expectancy is more than 10 years: Options are RP with lymphadenectomy (lymph node dissection [LND])[ 36 ] (EL-1) or EBRT + 6 months of ADT (EL-2). [ 32 33 34 35 ] …”

“…If life expectancy is between 5 and 10 years: Options include active surveillance, RP, or EBRT with 6 months of androgen deprivation therapy (ADT) (EL-2)[ 15 16 17 32 33 34 35 ]…”

“…If life expectancy is more than 10 years: Options are RP with lymphadenectomy (lymph node dissection [LND])[ 36 ] (EL-1) or EBRT + 6 months of ADT (EL-2). [ 32 33 34 35 ]…”