Long-Term Follow-Up of a Large Active Surveillance Cohort of Patients With Prostate Cancer

Abstract

Purpose Active surveillance is increasingly accepted as a treatment option for favorable-risk prostate cancer. Long-term follow-up has been lacking. In this study, we report the long-term outcome of a large active surveillance protocol in men with favorable-risk prostate cancer. Patients and Methods In a prospective single-arm cohort study carried out at a single academic health sciences center, 993 men with favorable- or intermediate-risk prostate cancer were managed with an initial expectant approach. Intervention was offered for a prostate-specific antigen (PSA) doubling time of less than 3 years, Gleason score progression, or unequivocal clinical progression. Main outcome measures were overall and disease-specific survival, rate of treatment, and PSA failure rate in the treated patients. Results Among the 819 survivors, the median follow-up time from the first biopsy is 6.4 years (range, 0.2 to 19.8 years). One hundred forty-nine (15%) of 993 patients died, and 844 patients are alive (censored rate, 85.0%). There were 15 deaths (1.5%) from prostate cancer. The 10- and 15-year actuarial cause-specific survival rates were 98.1% and 94.3%, respectively. An additional 13 patients (1.3%) developed metastatic disease and are alive with confirmed metastases (n = 9) or have died of other causes (n = 4). At 5, 10, and 15 years, 75.7%, 63.5%, and 55.0% of patients remained untreated and on surveillance. The cumulative hazard ratio for nonprostate-to-prostate cancer mortality was 9.2:1. Conclusion Active surveillance for favorable-risk prostate cancer is feasible and seems safe in the 15-year time frame. In our cohort, 2.8% of patients have developed metastatic disease, and 1.5% have died of prostate cancer. This mortality rate is consistent with expected mortality in favorable-risk patients managed with initial definitive intervention.

Active surveillance in Canadian men with low-grade prostate cancer

“…Consistent with other active surveillance cohorts, 12,20,[22][23][24] the majority of patients in this study remained on active surveillance during follow-up. In accordance with our results, some series have reported reclassification to highergrade cancer on repeat biopsy as the main reason for initiation of treatment after a period of active surveillance.…”

“…Evidence suggests that active surveillance for low-grade prostate cancer is a safe and feasible management option that is well tolerated by patients 9,10 and does not substantially compromise oncologic outcomes. 11,12 Although a variety of selection criteria for active surveillance exist, most patients with a diagnosis of low-grade (Gleason score 6) cancer may be candidates. 13,14 Current Cancer Care Ontario guidelines list active surveillance as the preferred management strategy for "low-risk (Gleason score ≤ 6) localized prostate cancer."…”

Active Surveillance of Prostate Cancer: Use, Outcomes, Imaging, and Diagnostic Tools

“…8 In Toronto, Klotz et al 5 initiated a program of AS aimed at low-risk and select intermediate-risk patients. Their monitoring protocol includes PSA measurements every 3 months for 2 years then every 6 months, with a confirmatory biopsy during the first year and then every 3 to 4 years until age 80.…”

“…3,4 Observations from two large, prospective AS cohorts reach nearly 20 years of follow-up and indicate very low likelihood of metastatic disease or prostate cancer-specific mortality in appropriately selected men. 5,6 Despite its utility in reducing overtreatment, AS is not without morbidity. 7 The contemporary practice of AS remains largely based upon frequent clinical examination, serum prostate-specific antigen (PSA) testing, and prostate biopsy, 8 a procedure associated with patient discomfort and serious complications including infection.…”

Circulating microRNA signature for the diagnosis of very high-risk prostate cancer

“…This may be reduced by improved risk stratification; men with LR and very low-risk (VLR) PCa can be monitored on active surveillance, whereas those with intermediate and high-risk (HR) PCa benefit from treatment (7)(8)(9)(10)(11). Treatment can be avoided in almost 70% of men in active surveillance at 15 y of follow-up (12). However, many urologists and patients are reluctant to monitor their cancer on active surveillance due to concerns for delaying treatment or potentially missing treatment of aggressive cancer during a window of cure.…”