Active Surveillance—Is It Feasible for Intermediate-risk Localised Prostate Cancer?

Abstract

Background Although active surveillance (AS) is a well-recognised treatment option for localised low-risk prostate cancer (LRPC), its role in the management of localised intermediate-risk prostate cancer (IRPC) is not clear yet and the available literature is slightly contradictory. Objective To compare the outcome of AS between LRPC and IRPC patients. Design, setting, and participants Between November 2002 and August 2019, 372 men with localised prostate cancer (PC) underwent AS in our hospital based on local departmental protocol. Outcome measurements and statistical analysis The primary outcome measures were overall survival, disease progression–free survival, treatment-free survival, and biochemical recurrence–free survival. Survival times in the low- and intermediate-risk groups were compared using Cox regression analysis. Results and limitations Out of 372 localised PC patients, 276 (74%) had LRPC and 96 (26%) IRPC. Overall, 86 (31.2%) low-risk and 25 (26%) intermediate-risk patients developed disease progression, and 86 (31.2%) low-risk and 22 (23%) intermediate-risk patients underwent active treatment. Among the treated patients, eight (2.9%) LRPC patients and one (1%) IRPC patient developed biochemical recurrence. In total, only one patient (from the low-risk group) had metastasis and 25 patients passed away (18 from the low-risk and seven from the intermediate-risk group). No death was recorded due to PC in the cohort. There was no difference in any of the survival outcomes between LRPC and IRPC patients in unadjusted analysis as well as when analysis was performed after adjusting the potentially confounding factors. Limitations include relatively short median follow-up time and failure to objectively define the criteria for the selection of IRPC patients suitable for AS. Conclusions The option of AS could be considered for carefully selected and well-informed patients with IRPC provided close structured monitoring is maintained. Patient summary In this report, we looked at various survival outcomes of active surveillance between low- and intermediate-risk prostate cancer patients in a large British population. There was no difference in any of the survival outcomes between the two groups. We concluded that carefully selected intermediate-risk prostate cancer patients could be offed the option of active surveillance.

Active Surveillance for Intermediate-risk Prostate Cancer: A Systematic Review, Meta-analysis, and Metaregression

“…Rather than defining a single criterion that can identify IR patients suitable for AS, there is promise in better understanding individual patient risk through multiple parame- ) during AS will help refine the selection of IR patients. Mukherjee et al [28] reported that as an initial stratification tool, MRI was useful in excluding patients with large-volume tumors (eg, Prostate Imaging Reporting and Data System score 5) from AS, and further studies are needed to determine whether better outcomes can be achieved in patients with no visible tumors or low-volume tumors on MRI. As a surveillance tool, progression on MRI was the trigger for definitive treatment in 14% [18] to 70.4% [15] of cases treated during follow-up, and future studies are needed to demonstrate whether MRI is useful in indicating early treatment before clinical progression.…”

“…9) relative to LR patients. Among the studies (n = 4) that compared the risk of PCa death in LR and IR patients, there were no PCa-related deaths in either group [26][27][28]31]. Allcause deaths were assessed in two studies [28,31].…”

“…Among the studies (n = 4) that compared the risk of PCa death in LR and IR patients, there were no PCa-related deaths in either group [26][27][28]31]. Allcause deaths were assessed in two studies [28,31]. Rakauskas et al [31] recorded no deaths in their cohort, and Mukherjee et al [28] found a similar rate of all-cause death between LR (18/276) and IR (7/96) PCa patients with GG 2 (p = 0.8).…”

“…Allcause deaths were assessed in two studies [28,31]. Rakauskas et al [31] recorded no deaths in their cohort, and Mukherjee et al [28] found a similar rate of all-cause death between LR (18/276) and IR (7/96) PCa patients with GG 2 (p = 0.8).…”

Prospective Implementation and Early Outcomes of a Risk-stratified Prostate Cancer Active Surveillance Follow-up Protocol

“…Most of these initiatives have mainly included men with classical low-risk disease with progression to grade group 2 as the end point. However, there is increasing recognition that grade group 2/favourable intermediate-risk/CPG2 disease is also suitable for management with AS, and this has been endorsed by national guidelines [1] , [4] , [28] , [29] , [30] . These men have a higher risk of progression (as we have shown in this study) and hence require closer follow-up, but the majority will do very well.…”