Impact of bilateral biopsy-detected prostate cancer on an active surveillance population

Abstract

Background To assess factors that can predict active surveillance (AS) failure on serial transrectal ultrasound guided biopsies in patients with low-risk prostate cancer. Methods We evaluated the records of 144 consecutive patients enrolled in AS between 2007 and 2014 at a single academic institution. Low risk inclusion criteria included PSA < 10 ng/ml, cT1c or cT2a, Grade Group (GG) 1, < 3 positive cores, and < 50% tumor in a single core with the majority having a PSA density of < 0.15. AS reclassification was defined as progression to GG ≥2, 3 or more cores, or core tumor volume ≥ 50%. Univariate and multivariate Cox proportional hazards regression analysis was used to determine predictors of reclassification and a match-pair analysis performed on a control group of patients choosing surgery. Results Inclusion criteria were met by 130 men with a median follow-up of 52 months. The reclassification or AS failure rate was 38.5%, with the majority 41/50 (82%) finding GG ≥ 2 cancer. Most patients had unilateral disease on diagnostic biopsy (94.6%), but 40.7% had bilateral cancer detected during follow-up. Men with bilateral detected tumor were more likely to ultimately fail AS than patients with unilateral tumors (HR 4.089; P < 0.0001) and failed earlier with a reclassification-free survival of 32 vs 119 months respectively. In a matched-pair analysis using a population of 211 concurrent patients that chose radical prostatectomy rather than AS, 76% of patients with unilateral cancer on biopsy had bilateral cancer on final pathology. Conclusions The finding of bilateral prostate cancer on biopsy is associated with earlier AS reclassification. Finding bilateral disease may not represent disease progression, but rather enhanced detection of more extensive disease highlighting the importance of confirmatory biopsy.

The Risk of Prostate Cancer Progression in Active Surveillance Patients with Bilateral Disease Detected by Combined Magnetic Resonance Imaging-Fusion and Systematic Biopsy

“…11 In a retrospective study published in 2019, Wang et al observed that bilateral disease detected on Sbx was the strongest risk factor for AS failure. 12 On AS reclassification-free survival analysis, they found that bilateral disease was associated with earlier reclassification on followup biopsy (32 months for bilateral disease vs 119 months for unilateral disease). We expand on this work by adding that detection of bilateral disease using mpMRI of the prostate and Cbx, rather than Sbx alone, was significantly associated with disease progression in patients on AS and finding that PSAD at the time of AS enrollment additionally predicted future progression.…”

Cumulative cancer locations on prostate biopsy and active surveillance outcomes in the MRI era

“…Validation of the CCLO score to predict AS outcomes in our large, comprehensive cohort lends further credence to the utility of tabulating both tumor quantity and location on prostate biopsy. Prior research has shown that tumor location within the prostate has implications for progression on AS and genomic heterogeneity among multifocal tumors 9,10 . Despite this knowledge, the importance of recording intraprostatic tumor location on biopsy is not emphasized in current guidelines for localized prostate cancer risk stratification 1,11,12 .…”

“…The discriminative ability to predict GR using Harrell's c-index implications for progression on AS and genomic heterogeneity among multifocal tumors. 9,10 Despite this knowledge, the importance of recording intraprostatic tumor location on biopsy is not emphasized in current guidelines for localized prostate cancer risk stratification. 1,11,12 The CCLO score can help to fill this gap by providing a shorthand notation of the number of prostate sextants involved with cancer in addition to the total volume of biopsied disease.…”

Long-term Outcomes Following Active Surveillance of Low-grade Prostate Cancer: A Population-based Study Using a Landmark Approach. Letter.

“…2 Another study found that bilateral Gleason 6 involvement predicted for early progression of disease and should be cautionary for AS. 3 In our practice, where Black individuals comprise three-quarters of the patient population, we recently showed that aggressive prostate cancer diagnoses are increasing. 4 Therefore, we caution vigilance for AS especially for high-risk groups such as Black men and those with adverse tumor-specific features.…”