Urologic Oncology: Seminars and Original Investigations
Original articleIdentifying intermediate-risk candidates for active surveillance of prostate cancer
Introduction
Active surveillance (AS) is widely recommended as a standard initial management option for men diagnosed with very low and low risk (LR), apparently localized prostate cancer (PCa) [1], [2], [3]. Its role in IR PCa [4], [5], [6] remains controversial, and many clinicians believe that all IR cases should be managed early because of an increased risk of metastatic disease, despite the fact that in many cases AS avoids overtreatment and associated morbidity [7], [8]. However, the PIVOT trial demonstrated that for men treated with radical prostatectomy for IR, screen detected PCa had no overall survival advantage compared to men treated with observation alone, suggesting the feasibility of a modern surveillance protocol in this patient group as well [9].
In this retrospective review, we describe our 21-year experience with AS in a cohort of men with very low-, low-, or intermediate-risk (IR) PCa managed in a tertiary referral center. We hypothesize that some men with IR disease can be safely monitored with AS if they are carefully selected . We have offered AS to men with IR disease with the knowledge that some will prove to have clinically insignificant cancers, whereas others with more aggressive disease will be uncovered and are only deferring therapeutic intervention for a period of time. In our series, we have analyzed the use of National Comprehensive Cancer Network (NCCN) favorable/unfavorable risk criteria and CAPRA score, as well as clinical, biochemical, and pathological parameters as predictors of progression in LR and IR candidates.
Section snippets
Data source and patient selection
Since 1993, men with clinically localized PCa have been offered AS at the Vancouver Prostate Centre (VPC). Their clinical data have been collected in an Institutional Review Board–approved, prospectively accrued database. Men have been followed with a well-defined protocol including digital rectal examination and prostate-specific antigen (PSA) measurements every 6 months, restaging confirmatory transrectal ultrasound (TRUS)–guided prostate biopsy within 18 months of first diagnosis and
Results
The clinical and pathological characteristics of the 651 patients meeting inclusion criteria are shown in Table 1. Mean age and PSA at diagnosis were 64.3 years and 5.7 ng/ml, respectively. Median follow-up for all groups was 4.5 years, with a range of 0.6 to 19.1 years (Table 1). More than 10-year follow-up was achieved in 54 men (8.2%) and more than 5-year follow-up in 293 men (45%).
Discussion
This study describes a 21-year experience of AS in a large cohort of patients with very low-, low- and intermediate-risk PCa. Most men with IR disease were “favorable” IR and were selected for AS because of individual priorities of sexual function and continence that outweighed the patient’s (and physician’s) concerns about the risk of imminent disease progression. Our results show extremely low rates of metastasis and PCa death in each of the very low-, low-, and intermediate-risk groups.
The
Conclusion
Parameters that predict for a lower risk of progression in patients with IR disease include the NCCN favorable IR criteria, a low CAPRA score, and a low percentage of biopsy cores involved. However, until we have a better biologically or image-based method of separating the “good actors” from the “bad actors,” the patient and physician should accept that selecting AS is better considered “AS with probable delayed intervention.” In our experience, the risks of progression to incurable PCa and
Acknowledgments
The authors would like to acknowledge the contribution of Mr. Kenny Lynch and Drs. Antonio Hurtado-Coll and Michael Peacock in data collation and resource management.
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