Role of Prostate Specific Antigen and Immediate Confirmatory Biopsy in Predicting Progression During Active Surveillance for Low Risk Prostate Cancer

Abstract

Purpose We evaluated predictors of progression after starting active surveillance, especially the role of prostate specific antigen and immediate confirmatory prostate biopsy. Materials and Methods A total of 238 men with prostate cancer met active surveillance eligibility criteria and were analyzed for progression with time. Cox proportional hazards regression was used to evaluate predictors of progression. Progression was evaluated using 2 definitions, including no longer meeting 1) full and 2) modified criteria, excluding prostate specific antigen greater than 10 ng/ml as a criterion. Results Using full criteria 61 patients progressed during followup. The 2 and 5-year progression-free probability was 80% and 60%, respectively. With prostate specific antigen included in progression criteria prostate specific antigen at confirmatory biopsy (HR 1.29, 95% CI 1.14–1.46, p <0.0005) and positive confir-matory biopsy (HR 1.75, 95% CI 1.01–3.04, p = 0.047) were independent predictors of progression. Of the 61 cases 34 failed due to increased prostate specific antigen, including only 5 with subsequent progression by biopsy criteria. When prostate specific antigen was excluded from progression criteria, only 32 cases progressed, and 2 and 5-year progression-free probability was 91% and 76%, respectively. Using modified criteria as an end point positive confirmatory biopsy was the only independent predictor of progression (HR 3.16, 95% CI 1.41–7.09, p = 0.005). Conclusions Active surveillance is feasible in patients with low risk prostate cancer and most patients show little evidence of progression within 5 years. There is no clear justification for treating patients in whom prostate specific antigen increases above 10 ng/ml in the absence of other indications of tumor progression. Patients considering active surveillance should undergo confirma-tory biopsy to better assess the risk of progression.

Active Surveillance for Prostate Cancer: A Systematic Review of the Literature

“…Twenty-seven percent of men were identified with adverse pathologic features on 12-core confirmatory biopsy, rendering them ineligible for surveillance per their protocol, while 26% of men demonstrated negative histology. A follow-up analysis with a larger sample size suggests that up to 35% of men may no longer be candidates after immediate rebiopsy [26]. Within the PRIAS cohort, 78.5% of men had either no cancer detected or cancer still meeting all criteria for surveillance after a confirmatory biopsy [35].…”

“…It is important to note, however, that many patients described in these series were included retrospectively and did not meet the ''strictest'' criteria often used in contemporary AS protocols. Table 2 depicts the reported outcomes from the reviewed AS series [24][25][26][27]. Not unexpectedly-and despite varying entry criteria-the disease-specific and all-cause survival over the short term is high.…”

Active surveillance in patients with a PSA >10 ng/mL

“…One series reports that half of those who "progressed" did so because of a rising PSA. 8 In that series PSA at diagnosis was only predictive of PSA progression, not grade or volume progression. Two series have now reported surveillance outcomes among intermediate risk disease, 9,10 though with short follow-up.…”

Oncologic Outcomes after Radical Retropubic Prostatectomy in Patients Meeting the Epstein Criteria

“…Active surveillance protocol of patients determined by these criteria includes intermittent digital rectal examination, PSA measurement, and rebiopsies. Among these, the most important is the rebiopsy that is performed within 1 year after the initial biopsy because the initial biopsy can fail to detect a high-level disease (13). If the cancer is negative or if the result in the first rebiopsy is the same as that in the initial biopsy, the interval between the biopsies can be increased up to 1-2 years.…”