Expectant Management of Prostate Cancer With Curative Intent: An Update of The Johns Hopkins Experience

Carter, H. Ballentine; Kettermann, Anna; Warlick, Christopher A.; Metter, E. Jeffrey; Landis, Patricia; Walsh, Patrick C.; Epstein, Jonathan I.

doi:10.1016/j.juro.2007.08.039

Cited by 307 publications

(156 citation statements)

References 15 publications

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“…We assumed as a base case that AS would provide 25% additional benefit compared with WW in preventing prostate cancer–specific death and used an HR for prostate cancer–specific death for treatment compared with AS of 1.85 (15). We changed 2 probabilities from the previous decision analysis to reflect the publication of updated results of AS cohorts (12, 22, 23, 25-28): The annual probability of Gleason progression on AS decreased to 2.3% from 2.7%, and the annual probability of developing other signs of disease progression increased to 5.2% from 2.7% (Table 1) (15). …”

Section: Methodsmentioning

confidence: 99%

Observation Versus Initial Treatment for Men With Localized, Low-Risk Prostate Cancer

Hayes¹,

Ollendorf²,

Pearson³

et al. 2013

Ann Intern Med

111

109

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Background Observation is underused among men with localized, low-risk prostate cancer. Objective To assess the costs and benefits of observation versus initial treatment. Design Decision analysis simulating treatment or observation. Data Sources Medicare schedules, published literature. Target Population Men ages 65 and 75 years with newly diagnosed low-risk prostate cancer (prostate-specific antigen level <10 μg/L, stage ≤T2a, Gleason score ≤3+3). Time Horizon Lifetime. Perspective Societal. Intervention Treatment (brachytherapy, intensity-modulated radiation therapy, or radical prostatectomy) or observation (active surveillance [AS] or watchful waiting [WW]). Outcome Measures Quality-adjusted life expectancy, costs. Results of Base-Case Analysis Observation was more effective and less costly than initial treatment. Compared with AS, WW provided 2 additional months of quality-adjusted life expectancy (9.02 vs. 8.85 years) at a savings of $15 374 ($24 520 vs. $39 894) in men aged 65 years and 2 additional months (6.14 vs. 5.98 years) at a savings of $11 746 ($18 302 vs. $30 048) in men aged 75 years. Brachytherapy was the most effective and least expensive initial treatment. Results of Sensitivity Analysis Treatment became more effective than observation when it led to more dramatic reductions in prostate cancer death (hazard ratio, 0.47 vs. WW and 0.64 vs. AS). Active surveillance became as effective as WW in men aged 65 years when the probability of progressing to treatment on AS decreased below 63% or when the quality of life with AS versus WW was 4% higher in men aged 65 years or 1% higher in men aged 75 years. Watchful waiting remained least expensive in all analyses. Limitation Results depend on outcomes reported in the published literature, which is limited. Conclusion Among these men, observation is more effective and costs less than initial treatment, and WW is most effective and least expensive under a wide range of clinical scenarios. Primary Funding Source National Cancer Institute, U.S. Department of Defense, Prostate Cancer Foundation, and Blue Shield of California Foundation.

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Section: Methodsmentioning

confidence: 99%

Observation Versus Initial Treatment for Men With Localized, Low-Risk Prostate Cancer

Hayes¹,

Ollendorf²,

Pearson³

et al. 2013

Ann Intern Med

111

109

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“…Multiple single-institution series suggest that a trial of active surveillance (AS) for select patients maintains urinary and sexual function and does not appreciably compromise disease-specific outcomes nor the ability for a delayed curative intervention 4, 7–10 . To better understand the durability and oncologic outcomes of AS, we compiled a multi-institutional cohort of patients who, based on age and a strict definition of low-risk cancer, were offered multiple management options but ultimately elected AS.…”

Section: Introductionmentioning

confidence: 99%

A Multi-Institutional Evaluation of Active Surveillance for Low Risk Prostate Cancer

et al. 2009

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Purpose For select men with low-risk prostate cancer, active surveillance (AS) is more often being considered a management strategy. In a multicenter retrospective study we evaluated the actuarial rates and predictors of remaining on AS, incidence of cancer progression, and pathologic findings of delayed radical prostatectomy. Methods A cohort of 262 men from four institutions met the following inclusion criteria: age ≤75, PSA ≤10 ng/ml, clinical stage T1-T2a, biopsy Gleason sum ≤6, ≤3 positive cores at diagnostic biopsy, a repeat biopsy before AS, and no treatment for six months following the repeat biopsy. AS started on the date of the second biopsy. Actuarial rates of remaining on AS were calculated and univariate Cox regression used to assess predictors of discontinuing AS. Results With a median follow-up of 29 months 43 patients ultimately received active treatment. The two and five-year probabilities of remaining on AS were 91% and 75%, respectively. Patients with cancer on the second biopsy (HR=2.23; 95% CI: 1.23–4.06; p=0.007) and a higher number of cancerous cores from the two biopsies combined (p=0.002) were more likely to undergo treatment. Age, PSA, clinical stage, prostate volume, and number of total biopsy cores sampled were not predictive of outcome. One patient developed skeletal metastases 38 months after starting AS. Of the 43 patients undergoing delayed treatment, 41 (95%) are without disease progression at a median of 23 months following treatment. Conclusions With a median follow-up of 29 months, AS for select patients appears to be safe and associated with a low risk of systemic progression. Cancer at restaging biopsy and a higher total number of cancerous cores are associated with a lower likelihood of remaining on AS. A restaging biopsy should be strongly considered to finalize eligibility for AS.

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“…The criteria we utilized for the consideration of AS and TRUS rebiopsy were based on the broadly utilized Epstein et al criteria and are more strict than several prior studies [5,8,12]. Specifically, we excluded stage T2 cancers, cancer in more than 2 cores, and biopsy tumor volume greater than 10%.…”

Section: Resultsmentioning

confidence: 99%

Impact of immediate TRUS rebiopsy in a patient cohort considering active surveillance for favorable risk prostate cancer

King

Livermore

Laurila

et al. 2013

Urologic Oncology: Seminars and Original Investigations

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Introduction and Objective Active surveillance (AS) is an option for the management of favorable risk prostate cancer (CaP) in the PSA era. Published studies have reported variable inclusion criteria for cohort selection. Accurate assessment of individual patient risk in AS is dependent not only upon rigorous selection criteria, but also reliability of diagnosis at tissue biopsy. To date, the impact of immediate transrectal ultrasound (TRUS) rebiopsy in confirming candidates for AS has been incompletely defined. Methods From a total of over 567 men, 67 met criteria for AS (Gleason <7, PSA <10, PSAD <0.15, <3 cores with <50% involvement of any 1 core). Fifty-two men agreed to a 12-core TRUS rebiopsy within 6 months of first diagnosis performed in clinic. Statistical analysis was performed using Wilcoxon signed rank test and logistic regression to determine predictors of rebiopsy characteristics, histopathologic outcomes, and impact on treatment choice. Results Mean cohort age was 63.9 years (range 56–72 years), PSA 5.9 ng/ml (4.1–10), and PSA density 0.12 ng/ml/cc at initial biopsy. Tumor involved 1.1 cores and 3.2% (range 1%–5%) of the total tissue. Average time to rebiopsy was 2.7 months. Notably, 29 of 52 men (56%) demonstrated no evidence of CaP on repeat biopsy; 14 of 23 men with a positive repeat biopsy showed either an increase in cancer volume (2.8% mean increase) and 9 (18%) were upgraded to Gleason pattern 3+4 = 7. Rebiopsy demonstrated 9 (17%) patients exceeded AS criteria. Nine patients chose curative surgical intervention (radical prostatectomy) based on increased cancer volume or grade (4) or an elective desire for treatment (5). All had organ confined disease with negative margins on final pathologic analysis. Statistical review revealed that initial Gleason score, PSA density, and number of positive cores at first biopsy were not predictive of men with higher volume/grade on re-biopsy. Conclusions Immediate TRUS repeat biopsy after diagnosis frequently fails to redemonstrate prostate cancer confirming the favorable-risk nature of disease burden in this group being considered for AS. A subset of patients are upgraded (17%) leading to reconsideration of AS. We conclude this clinic-based approach provides valuable additional information to discriminate appropriate AS candidates.

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Expectant Management of Prostate Cancer With Curative Intent: An Update of The Johns Hopkins Experience

Cited by 307 publications

References 15 publications

Observation Versus Initial Treatment for Men With Localized, Low-Risk Prostate Cancer

Observation Versus Initial Treatment for Men With Localized, Low-Risk Prostate Cancer

A Multi-Institutional Evaluation of Active Surveillance for Low Risk Prostate Cancer

Impact of immediate TRUS rebiopsy in a patient cohort considering active surveillance for favorable risk prostate cancer

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