Expanded criteria for active surveillance in prostate cancer: a review of the current data

Abstract

Over the last ten years, active surveillance (AS) has become increasingly utilized for patients with low-risk prostate cancer. Appropriately selected AS patients have a 10-year prostate cancer-specific mortality (PCSM) approaching 99%. Therefore, some institutions have expanded the inclusion criteria for AS to avoid the unnecessary morbidity associated with overtreatment. In this review, data from several high-quality studies were compiled to demonstrate how AS inclusion criteria may be safely expanded. Although AS criteria, data reporting, and statistical methods were heterogeneous across studies, several findings were consistent and provided insight for clinical practice. Gleason score ≥3+4 and prostate specific antigen density (PSAd) ≥0.15 ng/mL were consistently associated poor oncologic outcomes [biopsy reclassification/progression, adverse pathology at prostatectomy, biochemical recurrence (BCR), and PCSM]. Maximum single-core involvement, number of positive cores, and clinical stage were not consistently associated with negative outcomes. These data support the safety of expanded AS inclusion criteria beyond Epstein’s very low-risk (VLR) criteria to include patients with clinical stage T2, up to 60% maximum core involvement, and up to 4 positive cores (Gleason 3+3 and ≤ PSAd 0.15 ng/mL). Furthermore, although it is clear that patients with intermediate-risk disease have poorer oncologic outcomes compared to low-risk, the absolute 10-year PCSM remains low and select patients may be optimally managed with AS. Although AS utilization is increasing, many men who might be safely managed with AS are still undergoing morbid and unnecessary definitive treatments. Further research into clinical parameters such as multiparametric magnetic resonance imaging (mpMRI) and genetic testing is required to improve the accuracy of patient stratification.

The Secret Life of Translation Initiation in Prostate Cancer

“…Indeed, PCa is a highly heterogeneous disease, comprising mostly adenocarcinomas that display a wide spectrum of both clinical evolution patterns and phenotypic defects (Humphrey, 2014; Seitzer et al, 2014; Network, 2015; Packer and Maitland, 2016; Arora and Barbieri, 2018). Nowadays, the parameters most used for surveillance, diagnosis, and design of treatments are the blood level of prostate-specific antigen (PSA), the biopsy clinical stage, and the Gleason score of tumors (Humphrey, 2014; Seitzer et al, 2014; Jones et al, 2018; Martin et al, 2018; McCrea et al, 2018).…”

An overview of translational prostate cancer cohorts for prognostic and predictive studies

“…Therefore, biomarkers that broaden these inclusion criteria are highly sought‐after. Currently, it is unclear if tissue‐based molecular testing or novel radiological techniques such as multiparametric MRI will be taking the lead in guiding therapy . As AS patients will follow the natural course of the disease, prognostic markers are of importance to correctly assess the risk of disease progression following diagnosis.…”

“…Currently, it is unclear if tissue-based molecular testing or novel radiological techniques such as multiparametric MRI will be taking the lead in guiding therapy. 18 As AS patients will follow the natural course of the disease, prognostic markers are of importance to correctly assess the risk of disease progression following diagnosis. Conversely, as AS patients are usually rigorously followed-up, these patients allow a particularly detailed monitoring of the progression patterns of early prostate cancer.…”

Establishing a Urine-Based Biomarker Assay for Prostate Cancer Risk Stratification

“…To avoid overtreatment and reduce potential treatment side effects such as urinary and erectile dysfunctions, active surveillance can be used for patients with low-risk PCa. Although there is no absolute consensus on the criteria of high-risk and low-risk PCa, Gleason score, cancer stage, percent of biopsy core with cancer, and PSA (prostate-specific antigen) have been used in clinical practice and many studies for PCa risk stratification, sometimes with additional consideration such as PSA density ( Selvadurai et al, 2013 ; Klotz et al, 2015 ; Tosoian et al, 2016 ; Jones et al, 2018 ). However, Gleason score, cancer stage, and cancer core information are all obtained from biopsy, and frequent or periodic biopsies are not amenable for patients.…”