Predicting progression in patients followed with active surveillance for low-risk prostate cancer.

Abstract

38 Background: Due to the inability to predict progression and need for treatment, patients with low-risk prostate cancer (LRPC) managed by active surveillance (AS) are subjected to repeated biopsies and their possible complications. We developed a nomogram predicting the risk of progression in patients on AS for LRPC. Methods: A retrospective review of all patients enrolled in an AS program at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1993 and 2012 was conducted. Demographic, clinical, and pathologic data for patients who met the inclusion criteria for AS (cT1 or cT2a, prostate-specific antigen [PSA] less than 10, Gleason 6 or less, no more than three positive biopsy cores and no greater than 50% involvement of any single core) on the diagnostic and the confirmatory biopsies were collected and used to develop a nomogram for predicting progression-free probability. Multivariable logistic regression analysis was used to model the association between each risk variable (age, PSA levels, clinical stage, biopsy features) and disease progression. Progression was defined as failure to meet the inclusion criteria during follow up. Results: A total of 1,095 patients were enrolled in an AS program at MSKCC during the study period, of which 680 met the inclusion criteria for AS on both the diagnostic and the confirmatory biopsies and had available follow-up. At a median follow-up of 3 years 101 patients progressed. A nomogram predicting the progression-free probability was designed based on characteristics at diagnosis, result of a confirmatory biopsy and the number of negative and positive surveillance biopsies to date. A concordance index of 0.596 was calculated. Conclusions: Conditioned upon external validation, this nomogram can be used to counsel patients on their risk of progression and their surveillance protocol can be adjusted appropriately, possibly avoiding unnecessary biopsies and preventing biopsy-related complications.

Active Surveillance for Prostate Cancer: A Systematic Review of Clinicopathologic Variables and Biomarkers for Risk Stratification

“…The extent of cancer on biopsy such as number of positive cores, cancer length and/or percentage of core involvement were also shown in the majority of studies to be important predictors of disease progression or the probability of remaining on AS (5, 9, 11, 14, 19, 21, 24, 25, 27, 32, 35, 40, 45–47). Bul et al (19) showed that the strongest predictors for short-term biopsy reclassification (> 2 positive cores or GS >6 at repeat biopsy) were PSA density and the number of positive cores (2 versus 1).…”

“…Bul et al (19) showed that the strongest predictors for short-term biopsy reclassification (> 2 positive cores or GS >6 at repeat biopsy) were PSA density and the number of positive cores (2 versus 1). One recent study by Sternberg et al (21) created a nomogram for progression on AS including age, clinical stage, PSA, number of positive cores at diagnosis, percent of positive cores at diagnosis, and number of positive and negative biopsies to date. Another study by Iremashvili et al (45) created a nomogram using race, PSA density and the total number of positive cores on diagnostic and first repeat biopsy to predict the probability of no progression on 2 nd –4 th repeat biopsies.…”

The importance of PSA-Density in active surveillance for prostate cancer

“…In the literature, many articles found that maximum percent core involvement at diagnosis was associated with progression (23-26). Sternberg et al (27) and Iremashvili et al (28) created nomograms that include number of positive cores and percent of positive cores at diagnosis. However, disease progression and extent of cancer on biopsy are not associated significantly in some studies (29,30).…”