Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience

Methodology to study the three-dimensional spatial distribution of prostate cancer and their dependence on clinical parameters

A methodology to study the relationship between clinical variables [e.g., prostate specific antigen (PSA) or Gleason score] and cancer spatial distribution is described. Three-dimensional (3-D) models of 216 glands are reconstructed from digital images of whole mount histopathological slices. The models are deformed into one prostate model selected as an atlas using a combination of rigid, affine, and B-spline deformable registration techniques. Spatial cancer distribution is assessed by counting the number of tumor occurrences among all glands in a given position of the 3-D registered atlas. Finally, a difference between proportions is used to compare different spatial distributions. As a proof of concept, we compare spatial distributions from patients with PSA greater and less than [Formula: see text] and from patients older and younger than 60 years. Results suggest that prostate cancer has a significant difference in the right zone of the prostate between populations with PSA greater and less than [Formula: see text]. Age does not have any impact in the spatial distribution of the disease. The proposed methodology can help to comprehend prostate cancer by understanding its spatial distribution and how it changes according to clinical parameters. Finally, this methodology can be easily adapted to other organs and pathologies.

Active Surveillance is an Appropriate Management Strategy for a Proportion of Men Diagnosed with Prostate Cancer by Prostate Specific Antigen Testing

PURPOSE

The purpose of this study was to determine the fraction of men who would qualify for active surveillance in a population based cohort diagnosed with prostate cancer. In those who qualified and subsequently underwent primary treatment with radical prostatectomy, we assessed the rate of upgrading and up staging.

MATERIALS AND METHODS

SABOR is a Clinical and Epidemiologic Center of the EDRN (Early Detection Research Network), NCI (National Cancer Institute), with 3,828 men enrolled at the time of review. Of these men 320 were diagnosed with prostate cancer, of whom 281 had sufficient data for review. These 281 cases were reviewed to determine suitability for active surveillance using 2 sets of criteria. Criteria 1 were prostate specific antigen density less than 15%, 2 or fewer cores involved with cancer, Gleason score 6 or less and cancer involving 50% or less of biopsy volume. Criteria 2 were 4 or fewer cores with Gleason 3 + 3 cancer and only 1 core of Gleason 3 + 4 cancer with up to 15% of core involved with Gleason 3 + 4 disease. For those undergoing radical prostatectomy, we examined rates of up staging and upgrading.

RESULTS

Of the 281 patients, 187 (67%) qualified for active surveillance under criteria 1 and/or 2. Treatment data were available on 178 patients, and 74 underwent radical prostatectomy. Using the initial biopsy, 14 men (33.1%) who met criteria 1 and 9 (25%) who met criteria 2 were upgraded and/or up staged on final pathological review. By comparison, 38% of those who did not qualify for active surveillance were upgraded and/or up staged.

CONCLUSIONS

In a population based cohort, two-thirds of men diagnosed with prostate cancer qualify for active surveillance. Less restricted criteria for surveillance may be appropriate based on similar rates of upgrading/up staging at radical prostatectomy.

The implications of prostate-specific antigen density to predict clinically significant prostate cancer in men ≤ 50 years

To investigate the appropriate cut-off level of PSA or other clinical parameters at aged ≤ 50 years. The rate of detection of PCa in young men will continue to rise associated with the advancement of the current and evolving practices of screening and detection. In this study, we determined whether to investigate the appropriate cut-off level of PSA or other clinical parameters at aged ≤ 50 years. The study population included 106 patients aged ≤ 50 years who had prostate biopsy at our institute. The differences of clinical variables including various PSA related parameters between the patients with significant PCa and insignificant PCa were analyzed. Receiver operating characteristics (ROC) curves and the corresponding areas under the ROC curves (AUC) were calculated. There were no significant differences between no-PCa and PCa patients regarding PSA value, prostate volume (P vol), PSA density (PSAD), transition zone volume (TZ vol), PSATZ density (PSATZD). When the patients meeting the following criteria, Gleason score was ≤ 6 with less than 2 positive biopsy cores, were classified as having insignificant prostate cancer, PSAD could become a useful predictor of significant PCa in men. The AUC was significantly greater in PSAD (0.801) than for the other parameters. The sensitivity and specificity of a PSAD threshold of 0.32 were 85.7% and 77.8%, respectively. In conclusion, PSAD can be a useful and very effective predictor in a man aged ≤ 50 and we can counsel patients with discretion regarding the likelihood of significant PCa.

Long-term follow-up of a large active surveillance cohort of patients with prostate cancer

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.

Five-year follow-up of active surveillance for prostate cancer: A Canadian community-based urological experience

INTRODUCTON

We assessed oncological outcomes of active surveillance (AS) using a community database and identified factors associated with disease reclassification on surveillance biopsy.

METHODS

A retrospective review was performed on 200 men on AS. Prostate-specific antigen (PSA) was measured every 3 to 6 months. Prostate biopsies were performed every 1 to 4 years, and at the individual physician's discretion. Disease reclassification was defined as clinical T1 to cT2 progression, or histologically as >2 cores positive, Gleason score >6, or >50% core involvement on surveillance biopsy. Multivariate Cox regression analysis evaluated factors associated with disease reclassification. Kaplan-Meier survival curves were plotted.

RESULTS

We assessed a heterogeneous cohort of 86 patients, with a median age 67.2 years, who received ≥1 surveillance biopsies. The median follow-up was 5.2 years. The median times to first and second surveillance biopsies were 730 and 763 days, respectively. Overall, 47% of patients were reclassified on surveillance biopsy after a median 2.1 years. Factors associated with disease reclassification were PSA density >0.20 (p < 0.0001, hazard ratio [HR] 4.55, 95% confidence interval [CI] 2.116-9.782) and ≥3 positive cores (p = 0.0152, HR 3.956, 95% CI 1.304-12.003) at diagnosis, and number of positive cores on surveillance biopsy. In total, 25 (29%) patients received delayed intervention, with a median time to intervention of 2.6 years. The median time on AS was 4.4 years, with an overall survival of 95% and prostate-specific survival of 100%.

CONCLUSIONS

Our community study supports AS to reduce over-treatment of prostate cancer. PSA density >0.20 and ≥3 cores positive are associated with disease reclassification on surveillance biopsy.

The prostate health index selectively identifies clinically significant prostate cancer

PURPOSE

The Prostate Health Index (phi) is a new test combining total, free and [-2]proPSA into a single score. It was recently approved by the FDA and is now commercially available in the U.S., Europe and Australia. We investigate whether phi improves specificity for detecting clinically significant prostate cancer and can help reduce prostate cancer over diagnosis.

MATERIALS AND METHODS

From a multicenter prospective trial we identified 658 men age 50 years or older with prostate specific antigen 4 to 10 ng/ml and normal digital rectal examination who underwent prostate biopsy. In this population we compared the performance of prostate specific antigen, % free prostate specific antigen, [-2]proPSA and phi to predict biopsy results and, specifically, the presence of clinically significant prostate cancer using multiple criteria.

RESULTS

The Prostate Health Index was significantly higher in men with Gleason 7 or greater and "Epstein significant" cancer. On receiver operating characteristic analysis phi had the highest AUC for overall prostate cancer (AUCs phi 0.708, percent free prostate specific antigen 0.648, [-2]proPSA 0.550 and prostate specific antigen 0.516), Gleason 7 or greater (AUCs phi 0.707, percent free prostate specific antigen 0.661, [-2]proPSA 0.558, prostate specific antigen 0.551) and significant prostate cancer (AUCs phi 0.698, percent free prostate specific antigen 0.654, [-2]proPSA 0.550, prostate specific antigen 0.549). At the 90% sensitivity cut point for phi (a score less than 28.6) 30.1% of patients could have been spared an unnecessary biopsy for benign disease or insignificant prostate cancer compared to 21.7% using percent free prostate specific antigen.

CONCLUSIONS

The new phi test outperforms its individual components of total, free and [-2]proPSA for the identification of clinically significant prostate cancer. Phi may be useful as part of a multivariable approach to reduce prostate biopsies and over diagnosis.

Whole prostate volume and shape changes with the use of an inflatable and flexible endorectal coil

Purpose. To determine to what extent an inflatable endorectal coil (ERC) affects whole prostate (WP) volume and shape during prostate MRI. Materials and Methods. 79 consecutive patients underwent T2W MRI at 3T first with a 6-channel surface coil and then with the combination of a 16-channel surface coil and ERC in the same imaging session. WP volume was assessed by manually contouring the prostate in each T2W axial slice. PSA density was also calculated. The maximum anterior-posterior (AP), left-right (LR), and craniocaudal (CC) prostate dimensions were measured. Changes in WP prostate volume, PSA density, and prostate dimensions were then evaluated. Results. In 79 patients, use of an ERC yielded no significant change in whole prostate volume (0.6 ± 5.7%, P = 0.270) and PSA density (−0.2 ± 5.6%, P = 0.768). However, use of an ERC significantly decreased the AP dimension of the prostate by −8.6 ± 7.8% (P < 0.001), increased LR dimension by 4.5 ± 5.8% (P < 0.001), and increased the CC dimension by 8.8 ± 6.9% (P < 0.001). Conclusion. Use of an ERC in prostate MRI results in the shape deformation of the prostate gland with no significant change in the volume of the prostate measured on T2W MRI. Therefore, WP volumes calculated on ERC MRI can be reliably used in clinical workflow.

Are active surveillance criteria sufficient for predicting advanced stage prostate cancer patients?

OBJECTIVES

To examine the treatment outcomes of the prostate cancer (PCa) patients treated by radical prostatectomy (RP) who could be good candidates for active surveillance (AS) and test the confidence and reliability of the AS criterias for predicting advanced stage disease (RP Gleason score≥7 or Pathological stage T3).

METHODS

Between 2005 and 2012 the records of the 401 patients who underwent RP with a diagnosis of PCa were examined. Of these patients, 173 were found to be candidates of AS. The inclusion criteria were as follows; clinical stage T2a or less, PSA<10ng/ml, 2 or fewer cores involved with cancer, no single core with 50% or greater maximum involvement of cancer, and no Gleason grade greater than 3 in the specimen.

RESULTS

Univariate analyzes revealed that patients with advanced stage disease have higher prostate specific antigen density (PSAD), higher maximum percent (max%) in positive cores and higher RP tumor volumes. In multivariate analyzes PSAD, max% in positive cores and RP tumor volumes were statistically significant determinants for advanced stage disease. ROC analyzes revealed that the RP tumor volume is a good test on advanced stage disease.

CONCLUSIONS

Decreasing the cutoff values for PSAD and max% in positive cores should be considered for AS inclusion criteria. If we could calculate the tumor volume before RP, we can minimize the treatment failures (over or undertreatment) of PCa. Perhaps new biopsy protocols, tissue biomarkers, and molecular imaging technology may refine AS criteria.

The critical role of the pathologist in determining eligibility for active surveillance as a management option in patients with prostate cancer: consensus statement with recommendations supported by the College of American Pathologists, International Society of Urological Pathology, Association of Directors of Anatomic and Surgical Pathology, the New Zealand Society of Pathologists, and the Prostate Cancer Foundation

CONTEXT

Prostate cancer remains a significant public health problem. Recent publications of randomized trials and the US Preventive Services Task Force recommendations have drawn attention to overtreatment of localized, low-risk prostate cancer. Active surveillance, in which patients undergo regular visits with serum prostate-specific antigen tests and repeat prostate biopsies, rather than aggressive treatment with curative intent, may address overtreatment of low-risk prostate cancer. It is apparent that a greater awareness of the critical role of pathologists in determining eligibility for active surveillance is needed.

OBJECTIVES

To review the state of current knowledge about the role of active surveillance in the management of prostate cancer and to provide a multidisciplinary report focusing on pathologic parameters important to the successful identification of patients likely to succeed with active surveillance, to determine the role of molecular tests in increasing the safety of active surveillance, and to provide future directions.

DESIGN

Systematic review of literature on active surveillance for low-risk prostate cancer, pathologic parameters important for appropriate stratification, and issues regarding interobserver reproducibility. Expert panels were created to delineate the fundamental questions confronting the clinical and pathologic aspects of management of men on active surveillance.

RESULTS

Expert panelists identified pathologic parameters important for management and the related diagnostic and reporting issues. Consensus recommendations were generated where appropriate.

CONCLUSIONS

Active surveillance is an important management option for men with low-risk prostate cancer. Vital to this process is the critical role pathologic parameters have in identifying appropriate candidates for active surveillance. These findings need to be reproducible and consistently reported by surgical pathologists with accurate pathology reporting.

Multiparametric magnetic resonance imaging in the management and diagnosis of prostate cancer: current applications and strategies

Magnetic resonance imaging (MRI) has become increasingly used worldwide in the diagnosis and management of prostate cancer. With advances in multiparametric MRI (mpMRI) technology, such as the use of dynamic contrast-enhanced and diffusion-weighted imaging sequences, observational studies have evaluated the utility for mpMRI in the continuum of prostate cancer management, from improving the detection of clinically significant prostate cancer, to planning radical prostatectomy and radiation therapy and the early detection of local recurrence. Furthermore, the potential for advanced imaging to reduce the burden of routine serial prostate needle biopsies for men on active surveillance is a promising area of research. MRI technology continues to evolve, and the potential applications in the management of prostate cancer care will require well-designed multi-institutional prospective clinical trials and rigorous efforts to standardize reporting and improve dissemination of expertise across institutions.

A solitary positive prostate cancer biopsy does not predict a unilateral lesion in radical prostatectomy specimens

OBJECTIVE

Prostate cancer (PCa) may be a multifocal and bilateral disease. Patients with low-risk PCa and a low number of positive biopsy cores may choose to undergo active surveillance or focal therapy. The aim of this study was to determine the correlation between a solitary positive prostate biopsy core and the pathological outcome after radical prostatectomy (RP).

MATERIAL AND METHODS

The Michinoku Japan Urological Cancer Study Group database contains data, including preoperative and postoperative information, on 1268 consecutive patients with PCa treated with RP alone at four institutions. This study focused on 151 patients with a single positive biopsy core, preoperative prostate-specific antigen (PSA) level less than 10 ng/ml, biopsy Gleason score less than 8, and clinical stage T1c/T2a/T2b disease. Potential preoperative predictors of unilateral PCa were age, preoperative PSA level, biopsy Gleason score and clinical T stage.

RESULTS

The median age and preoperative PSA level were 65 years (range 47-76 years) and 6.00 ng/ml (range 0.50-9.80 ng/ml), respectively. Unilateral PCa was identified in 41% of the patients. Extraprostatic extension or seminal vesicle invasion was observed in 26% of all patients.

CONCLUSION

Serum PSA levels were significantly higher in the bilateral PCa group than in the unilateral PCa group in the current study. For patients with PCa having a solitary positive prostate biopsy core, definitive therapy such as RP should be considered.

Predictive factors of unfavorable prostate cancer in patients who underwent prostatectomy but eligible for active surveillance

PURPOSE

To investigate the predictive factors of unfavorable prostate cancer in Korean men who underwent radical prostatectomy but eligible for active surveillance according to Epstein criteria.

METHODS

We retrospectively reviewed the medical records of 2,036 patients who underwent radical prostatectomy for prostate cancer between 1994 and 2011. Among these, 233 patients were eligible for active surveillance based on Epstein criteria. Unfavorable prostate cancer was defined as pathologic Gleason sum ≥7 or non-organ-confined disease. We investigated pathologic outcomes and predictive factors for unfavorable prostate cancer.

RESULTS

Of 233 cases, 91 patients (39.1%) were pathologic Gleason sum ≥7, 11 (4.7%) had extracapsular extension, and three (1.3%) had seminal vesicle invasion. Ninety-eight patients (42.1%) had unfavorable prostate cancer. When comparing clinically insignificant and significant prostate cancer, there were significant differences in mean age (P=0.007), prostate volume (P=0.021), prostate-specific antigen (PSA) density (P=0.03), maximum tumor volume in biopsy core (P<0.001), and rate of two positive cores (P=0.001). On multivariate analysis, age (P=0.015), PSA density (P=0.017) and two positive cores (P=0.001) were independent predictive factors for unfavorable prostate cancer.

CONCLUSIONS

A significant proportion of patients who were candidates for active surveillance had unfavorable prostate cancer. Age, PSA density, and two positive cores were independent significant predictive factors for unfavorable prostate cancer. These factors should be considered when performing active surveillance.

Vulnerabilities of PTEN-TP53-deficient prostate cancers to compound PARP-PI3K inhibition

Prostate cancer is the most prevalent cancer in males, and treatment options are limited for advanced forms of the disease. Loss of the PTEN and TP53 tumor suppressor genes is commonly observed in prostate cancer, whereas their compound loss is often observed in advanced prostate cancer. Here, we show that PARP inhibition triggers a p53-dependent cellular senescence in a PTEN-deficient setting in the prostate. Surprisingly, we also find that PARP-induced cellular senescence is morphed into an apoptotic response upon compound loss of PTEN and p53. We further show that superactivation of the prosurvival PI3K-AKT signaling pathway limits the efficacy of a PARP single-agent treatment, and that PARP and PI3K inhibitors effectively synergize to suppress tumorigenesis in human prostate cancer cell lines and in a Pten/Trp53-deficient mouse model of advanced prostate cancer. Our findings, therefore, identify a combinatorial treatment with PARP and PI3K inhibitors as an effective option for PTEN-deficient prostate cancer.

SIGNIFICANCE

The paucity of therapeutic options in advanced prostate cancer displays an urgent need for the preclinical assessment of novel therapeutic strategies. We identified differential therapeutic vulnerabilities that emerge upon the loss of both PTEN and p53, and observed that combined inhibition of PARP and PI3K provides increased efficacy in hormone-insensitive advanced prostate cancer.

Management of low risk prostate cancer-active surveillance and focal therapy

Low-risk prostate cancer, defined as Gleason Score 6 or less with PSA <10 ng/ml, is diagnosed in about half of men undergoing screening. Approximately 30% of men diagnosed with low-risk disease harbour high-grade cancer that is unrepresented on the biopsy. Moreover, a small percentage of low-grade cancers have molecular alterations that result in progression to aggressive disease. Favourable-risk prostate cancer should be managed with close follow up. Active surveillance is appropriate for most patients with low-risk disease, and radical treatment should be reserved for cases in which higher-risk disease is identified. In turn, focal therapy aims to preserve tissue and function in men who have been diagnosed with localized disease, and should be offered to men with higher risk disease at baseline, as an alternative to whole-gland radiation or surgery, or when the patient transitions from low-risk to higher-risk disease. The two strategies should be viewed as complementary elements of care that can be applied in a risk-stratified manner. In this Review, we discuss the rationale and current status of active surveillance-which constitutes a standard of care in most evidence-based guidelines-and comment on whether and when focal therapy should complement it in those men wishing to continue a tissue-preserving strategy.

Racial variation in prostate cancer upgrading and upstaging among men with low-risk clinical characteristics

BACKGROUND

African American (AA) men suffer a higher prostate cancer (PCa) burden than other groups.

OBJECTIVE

We aim to determine the impact of race on the risk of upgrading, upstaging, and positive surgical margins (PSM) at radical prostatectomy (RP) among men eligible for active surveillance.

DESIGN, SETTING, AND PARTICIPANTS

We studied men with low-risk PCa treated with RP at two centers. Low clinical risk was defined by National Comprehensive Cancer Network criteria. Outcome variables were upgrading, upstaging, and PSMs at surgery. Associations between race and the outcomes were evaluated with logistic regression adjusted for age, relationship status, diagnostic prostate-specific antigen level, percentage of positive biopsy cores, surgical approach, year of diagnosis, and clinical site.

RESULTS AND LIMITATIONS

Of 9304 men diagnosed with PCa, 4231 were low risk and underwent RP within 1 yr. Men were categorized as AA (n=273; 6.5%), Caucasian (n=3771; 89.1%), or other racial/ethnic group (Other; n=187; 4.4%). AA men had a significantly younger mean age (58.7 yr; standard deviation: ±7.06), and fewer (85%) were married or had a partner. Upgrading (34%) and upstaging (13%) rates did not significantly differ among the groups. The PSM rate was significantly higher in AA men (31%) than in the Caucasian (21%) and Other (20%) groups (p<0.01). We found an association between race group and PSM rate (p<0.03), with higher odds of PSMs in AA men versus Caucasian men (odds ratio [OR]: 1.64; 95% confidence interval [CI], 1.08-2.47). No statistically significant associations between race and rates of upgrading and upstaging were found. This study was limited by the relatively low proportion of AA men in the cohort.

CONCLUSIONS

Among clinically low-risk men who underwent RP, AA men had a higher likelihood of PSMs compared with Caucasian men. We did not find statistically significantly different rates of upgrading and upstaging between the race groups.

PATIENT SUMMARY

We analyzed two large groups of men with what appeared to be low-risk prostate cancer based on the initial biopsy findings. The likelihood of finding worse disease (higher grade or stage) at the time of surgery was similar across different racial groups.

The role of magnetic resonance imaging in delineating clinically significant prostate cancer

OBJECTIVE

To determine whether multiparametric magnetic resonance imaging might improve the identification of patients with higher risk disease at diagnosis and thereby reduce the incidence of undergrading or understaging.

METHODS

We retrospectively reviewed the clinical records of 115 patients who underwent multiparametric magnetic resonance imaging before radical prostatectomy. We used Epstein's criteria of insignificant disease with and without a magnetic resonance imaging (MRI) parameter (apparent diffusion coefficient) to calculate sensitivity, specificity, as well as negative and positive predictive values [NPV and PPV] across varying definitions of clinically significant cancer based on Gleason grade and tumor volume (0.2 mL, 0.5 mL, and 1.3 mL) on whole-mount prostate specimens. Logistic regression analysis was performed to determine the incremental benefit of MRI in delineating significant cancer.

RESULTS

The majority had a prostate-specific antigen from 4.1-10.0 (67%), normal rectal examinations (90%), biopsy Gleason score ≤ 6 (68%), and ≤ 2 cores positive (55%). Of the 58 patients pathologically staged with Gleason 7 or pT3 disease at prostatectomy, Epstein's criteria alone missed 12 patients (sensitivity of 79% and NPV of 68%). Addition of apparent diffusion coefficient improved the sensitivity and NPV for predicting significant disease at prostatectomy to 93% and 84%, respectively. MRI improved detection of large Gleason 6 (≥ 1.3 mL, P = .006) or Gleason ≥ 7 lesions of any size (P <.001).

CONCLUSION

Integration of MRI with existing clinical staging criteria helps identify patients with significant cancer. Clinicians should consider utilizing MRI in the decision-making process.

Active surveillance for low-risk prostate cancer: diversity of practice across Europe

BACKGROUND

Active surveillance (AS) is a recognised treatment option for low-risk prostate cancer (PCa).

AIMS

To review AS criteria in terms of patient selection, follow-up and indications for intervention.

METHODS

A total of 2,959 potential participants were identified and invited via email to complete an online survey. Only urologists practising in an EU country were eligible to participate. Statistical analyses were carried out using SPSS version 18.0. The χ (2) test was used to compare responses between those who do and do not follow an AS protocol.

RESULTS

Response rate was 8% (n = 226). Ninety-seven per cent urologists offer AS; 25% (n = 53/215) within a clinical trial and a further 28% (n = 60/215) using an official AS protocol. Gleason score ≤ 3 + 3 = 6 (87 %, n = 173/200) and prostate-specific antigen (PSA) ≤ 10 ng/ml (86%, n = 170/198) are the commonest selection criteria. There was a statistically significant association between having an AS protocol and using PSA as an eligibility criterion (p = 0.03). For urologists not following a protocol, 11% do not consider PSA as an eligibility criterion and 81% consider PSA ≤ 10 ng/ml to decide on AS, compared to 2 and 90%, respectively, who adhere to a protocol. Twenty-four per cent of urologists without a protocol do not re-biopsy in comparison to 11% with a protocol (p = 0.026). Gleason score progression trigger the most intervention (n = 168/192, 87%).

CONCLUSIONS

Urologists not adhering to an AS protocol or participating in a clinical trial appear to apply less rigorous criteria for both eligibility and monitoring in AS.

Prostate cancer prevention: agent development strategies

Despite advances in surgery, radiation, and medical therapy over the past decade and the widespread adoption of PSA screening, prostate cancer continues to be the second leading cause of cancer death in men in the United States. Invasive cancer is the end result of carcinogenesis, a chronic process occurring over many years driven by genetic and epigenetic alterations. The protracted nature of this transformation to the malignant phenotype provides an opportunity to intervene pharmacologically to prevent, reverse, or delay carcinogenesis, i.e. chemoprevention. Herein, we describe the unique features of cancer prevention, as opposed to cancer treatment, agent development clinical trials, and provide a summary of the ongoing research in this field being supported by the National Cancer Institute.

Value of transition zone biopsy in active surveillance of prostate cancer

PURPOSE

For patients on active surveillance there are limited data on transition zone sampling upon followup biopsy. We verified the value of transition zone biopsy in the active surveillance setting.

MATERIALS AND METHODS

Our study included 1,059 sets of prostate biopsies from a total of 534 patients on active surveillance at the Johns Hopkins Hospital. Each set comprised at least 14 cores with 2 or more from the transition zone. Of these men 53 underwent radical prostatectomy.

RESULTS

Patients with tumors in the peripheral zone as well as the transition zone had a higher maximum Gleason score and an increased maximum percent of cancer per core than men with tumor in the peripheral or transition zone only. In 12 of the 534 patients (2.2%) the tumor on active surveillance biopsy was limited to transition zone core(s). Of the 534 patients 11 (2.1%) had tumor with a high Gleason score (greater than 6) or extensive involvement (greater than 50%) of any core exclusively on transition zone biopsy. However, in 10 of 15 radical prostatectomy cases (66.7%) with prior positive transition zone biopsies the tumors had little or no transition zone component. In addition, transition zone status on biopsy had no significant relationship with Gleason score, extraprostatic extension or seminal vesicle involvement at radical prostatectomy.

CONCLUSIONS

Our data suggest that the additional yield is sufficiently low to argue against routine transition zone sampling in men undergoing followup biopsy on active surveillance. However, further study is needed to make definitive recommendations.

Oncological outcomes in patients potentially eligible for active surveillance who underwent radical prostatectomy

OBJECTIVE

To determine whether there are differences in the oncological outcomes after radical prostatectomy (adverse pathology and biochemical recurrence) based on clinical selection criteria used in two active surveillance (AS) protocols.

MATERIAL AND METHODS

442 patients diagnosed with localized prostate cancer (CP) underwent radical prostatectomy at our institution between August 2003 and December 2009. We selected patients with low-risk CP, which could have been included in an AS program. Patients were divided into two groups: group i, those who met the most strict surveillance criteria described by Epstein (PSAD<.15; T1/T2a;<2 positive core, Gleason≤6,<50% involvement of the core) and group ii, those meeting the more open criteria described by Klotz (PSA≤10 or<15 at age 70, Gleason≤6 or<7 [3+4] in over 70 years). We compared both groups to determine differences in pathological stage, positive surgical margins and biochemical recurrence after radical prostatectomy.

RESULTS

Of the 442 patients 48% (213 patients) had low-risk PC, and become potential candidates for an AS program. Of the patients operated on 17% (76 patients) met the criteria for AS as of Epstein's and 48% (213 patients) according to Klotz. Comparing patients in both groups there were no statistically significant differences in the presence of pT3 (7.9% vs 10.8%) P=.55, positive margins (22.4% vs. 28.3%) P=.41, nor in biochemical recurrence at 3 years (5.3% vs 5.6%) P=.86.

CONCLUSIONS

In our series of patients theoretically candidates for inclusion in a program of active surveillance, we found no differences in the percentage of patients with pathological stage pT3, positive margins and biochemical recurrence according to clinical inclusion criteria currently used.

Active surveillance: patient selection

PURPOSE OF REVIEW

This is a summary of the current approach to patient selection for active surveillance, including eligibility criteria, current controversies and the role of imaging.

RECENT FINDINGS

Active surveillance is based on the concept that Gleason 6 prostate cancer is, in most cases, an indolent condition that poses little or no threat to the patient's life. Substantial recent data suggest that Gleason pattern 3 does not have the molecular characteristics of malignancy. A subset of patients harbour more aggressive disease that was missed on the initial diagnostic biopsies, and a smaller group will progress over time to higher grade disease. Active surveillance involves initial expectant management for patients with favourable risk disease, and serial biopsy and prostate-specific antigen (PSA). Most patients with Gleason 6 prostate cancer are candidates. Very low risk patients fulfil the Epstein criteria, with only one or two positive cores, no core with more than 50% involvement and a PSA density of less than 0.15. Low-risk patients have Gleason 6 disease and PSA 10 or less but do not satisfy the Epstein criteria. Higher volume of Gleason 6 disease on biopsy predicts for a higher likelihood of higher grade cancer, but in and of itself should not mandate treatment. Patients with Gleason 7 in whom the extent of Gleason 4 pattern is less than 10% may also be candidates. Patient age, comorbidity and personal preferences must also be considered.

SUMMARY

Active surveillance is an effective and well tolerated method to reduce the overtreatment associated with screen-detected prostate cancer. About 50% of newly diagnosed patients are eligible for this approach. Multiple factors, including patient age, comorbidity, cancer risk category and patient preferences, must be considered.

Active surveillance for prostate cancer: overview and update

Low-risk prostate cancer: How I would treat it? Overtreatment of many conditions diagnosed by screening has become increasingly recognized as a contemporary malady associated with modern medicine's efforts at earlier detection. The diagnosis of low-grade prostate cancer clearly qualifies as an example of potential overdiagnosis and overtreatment. Active surveillance for low-risk prostate cancer is an attempt to reduce the overtreatment of the disease. The approach involves initial expectant management rather than immediate therapy. Curative treatment is deferred while the patient is monitored and offered for evidence of risk reclassification to a more aggressive form of the disease. The basis for this approach is substantial evidence confirming the long natural history of most prostate cancers. The objective is to balance the risks of overtreatment and associated adverse quality of life effects, against the risk of progression of disease and a missed opportunity for curative therapy. Low-risk prostate cancer is more accurately viewed as one of several risk factors for the patient harboring higher-grade disease, rather than a life-threatening condition. This approach is similar to that taken historically for so-called precancerous conditions, such as PIN or ASAP, where patients were managed with close follow-up but without radical intervention unless clear evidence of more aggressive disease is identified. Active surveillance is increasingly viewed as the management of choice for patients with very low-risk (low-grade, low-volume prostate cancer) and low-risk (low-grade but higher volume) disease.

Divorcing diagnosis from treatment: contemporary management of low-risk prostate cancer

Today, the majority of men with newly diagnosed prostate cancer will present with low-risk features of the disease. Because prostate cancer often takes an insidious course, it is debated whether the majority of these men require radical treatment and the accompanying derangement of quality of life domains imposed by surgery, radiation, and hormonal therapy. Investigators have identified various selection criteria for "insignificant disease," or that which can be monitored for disease progression while safely delaying radical treatment. In addition to the ideal definition of low risk, a lack of randomized trials comparing the various options for treatment in this group of men poses a great challenge for urologists. Early outcomes from active surveillance cohorts support its use in carefully selected men with low-risk disease features, but frequent monitoring is required. Patient selection and disease monitoring methods will require refinement that will likely be accomplished through the increased use of biomarkers and specialized imaging techniques.

Vitamin D3 supplementation, low-risk prostate cancer, and health disparities

Vitamin D promotes the differentiation of prostate cancer cells, raising the possibility that vitamin D deficiency over time may contribute to the progression from subclinical prostate cancer to clinical disease. Since low-risk prostate cancers are monitored over time in an effort to determine which progress into clinically important, more aggressive cancers, they provide an excellent model in which to study, over an extended period of time, the effects of enhancing vitamin D status and related changes in tumor progression. This is particularly relevant to African-American men, who exhibit a high prevalence of vitamin D deficiency as well as higher incidence of prostate cancer and higher mortality rates from prostate cancer than Caucasians. Our research team has recently completed an open-label clinical trial aimed at assessing the safety and potential efficacy of vitamin D3 supplementation at 4000 international units (IU) per day for one year in subjects diagnosed with early stage, low-risk prostate cancer. The results of this clinical study suggest that supplementation with vitamin D3 at 4000IU per day may benefit patients with early stage, low-risk prostate cancer on active surveillance, because of the improved outcome (a decreased number of positive cores at repeat biopsy) in more than half of the subjects enrolled in the trial. We also observed that, after one year of supplementation, there was no difference in circulating levels of vitamin D between African-American and Caucasian subjects who completed the study. These clinical results also suggest that robust and sustained vitamin D3 supplementation can reduce prostate cancer-related health disparities in African-American men and that these health disparities are at least in part the result of widespread hypovitaminosis D within the African-American population. This article is part of a Special Issue entitled 'Vitamin D Workshop'.

Active surveillance for prostate cancer: an underutilized opportunity for reducing harm

The management of localized prostate cancer is controversial, and in the absence of comparative trials to inform best practice, choices are driven by personal beliefs with wide variation in practice patterns. Men with localized disease diagnosed today often undergo treatments that will not improve overall health outcomes, and active surveillance has emerged as one approach to reducing this overtreatment of prostate cancer. The selection of appropriate candidates for active surveillance should balance the risk of harm from prostate cancer without treatment, and a patient's personal preferences for living with a cancer and the potential side effects of curative treatments. Although limitations exist in assessing the potential for a given prostate cancer to cause harm, the most common metrics used today consider cancer stage, prostate biopsy features, and prostate-specific antigen level together with the risk of death from nonprostate causes based on age and overall state of health.

Active surveillance: the Canadian experience with an "inclusive approach"

Active surveillance has evolved to become a standard of care for favorable-risk prostate cancer. This is a summary of the rationale, method, and results of active surveillance beginning in 1995 with the first prospective trial of this approach. This was a prospective, single-arm cohort study. Patients were managed with an initial expectant approach. Definitive intervention was offered to those patients with a prostate-specific antigen (PSA) doubling time of less than 3 years, Gleason score progression (to 4+3 or greater), or unequivocal clinical progression. Survival analysis and Cox proportional hazard model were applied to the data. Since November 1995, 450 patients have been managed with active surveillance. The cohort included men under 70 with favorable-risk disease and men of age more than 70 with favorable- or intermediate-risk cancer (Gleason score 3+4 or PSA 10-15). Median follow-up is 6.8 years (range 1-16 years). Overall survival is 78.6%. Ten-year prostate cancer actuarial survival is 97.2%. Five of 450 patients (1.1%) have died of prostate cancer. Thirty percent of patients have been reclassified as higher-risk patients and offered definitive therapy. The commonest indication for treatment was a PSA doubling time less than 3 years (48%) or Gleason upgrading (26%). Of 117 patients treated radically, the PSA failure rate was 50%. This represents 13% of the total cohort. Most PSA failures occurred early; at 2 years, 44% of the treated patients had PSA failure. The hazard ratio for non-prostate cancer mortality to prostate cancer mortality was 18.6 at 10 years. In conclusion, we observed a very low rate of prostate cancer mortality in an intermediate time frame. Among the one-third of patients who were reclassified as higher risk and retreated, PSA failure was relatively common. However, other-cause mortality accounted for almost all of the deaths. Further studies are warranted to improve the identification of patients who harbor more aggressive disease in spite of favorable clinical parameters at diagnosis [reproduced from Klotz (1) with permission from Wolters Kluwer Health].

Quality of life in men undergoing active surveillance for localized prostate cancer

Active surveillance is an important arrow in the quiver of physicians advising men with prostate cancer. Quality-of-life considerations are paramount for patient-centered decision making. Although the overall deleterious impact on health is less dramatic than for those who pursue curative treatment, men on active surveillance also suffer sexual dysfunction and distress. Five-year outcomes revealed more erectile dysfunction (80% vs 45%) and urinary leakage (49% vs 21%) but less urinary obstruction (28% vs 44%) in men undergoing prostatectomy. Bowel function, anxiety, depression, well-being, and overall health-related quality of life (HRQOL) were similar after 5 years, but at 6-8 years, other domains of HRQOL, such as anxiety and depression, deteriorated significantly for those who chose watchful waiting. Further research is needed to compare prospectively HRQOL outcomes in men choosing active surveillance and those never diagnosed with prostate cancer, in part to help weigh the potential benefits and harms of prostate cancer screening.

Observation versus initial treatment for men with localized, low-risk prostate cancer: a cost-effectiveness analysis

BACKGROUND

Observation is underutilized among men with localized, low-risk prostate cancer.

OBJECTIVE

To assess the costs and benefits of observation versus initial treatment.

DESIGN

Decision analysis simulating treatment or observation.

DATA SOURCES

Medicare schedules, published literature.

TARGET POPULATION

Men aged 65 and 75 years who had newly diagnosed low-risk prostate cancer (prostate-specific antigen level <10 µg/L, stage ≤T2a, Gleason score ≤3 + 3).

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Treatment (brachytherapy, intensity-modulated radiation therapy, or radical prostatectomy) or observation (active surveillance [AS] or watchful waiting [WW]).

OUTCOME MEASURES

Quality-adjusted life expectancy and costs.

RESULTS OF BASE-CASE ANALYSIS

Observation was more effective and less costly than initial treatment. Compared with AS, WW provided 2 additional months of quality-adjusted life expectancy (9.02 vs. 8.85 years) at a savings of $15,374 ($24,520 vs. $39,894) in men aged 65 years and 2 additional months (6.14 vs. 5.98 years) at a savings of $11,746 ($18,302 vs. $30,048) in men aged 75 years. Brachytherapy was the most effective and least expensive initial treatment.

RESULTS OF SENSITIVITY ANALYSIS

Treatment became more effective than observation when it led to more dramatic reductions in prostate cancer death (hazard ratio, 0.47 vs. WW and 0.64 vs. AS). Active surveillance became as effective as WW in men aged 65 years when the probability of progressing to treatment on AS decreased below 63% or when the quality of life with AS versus WW was 4% higher in men aged 65 years or 1% higher in men aged 75 years. Watchful waiting remained least expensive in all analyses.

LIMITATION

Results depend on outcomes reported in the published literature, which is limited.

CONCLUSION

Among these men, observation is more effective and costs less than initial treatment, and WW is most effective and least expensive under a wide range of clinical scenarios.

PRIMARY FUNDING SOURCE

National Cancer Institute, U.S. Department of Defense, Prostate Cancer Foundation, and Institute for Clinical and Economic Review.

Prostate cancer prevention: strategies for agent development

PURPOSE OF REVIEW

This article provides an update of clinical research supported by the National Cancer Institute's Phase I/II prostate cancer chemoprevention agent development program.

RECENT FINDINGS

Numerous clinical trials of pharmacologic interventions to delay, prevent or reverse carcinogenesis ('chemoprevention') with the ultimate goal of reducing cancer incidence have been conducted over the past decade. These trials range from relatively small, short-duration studies with biomarker endpoints to very large, long-term, general population trials with definitive cancer endpoints. Two large, population-based, Phase III prostate cancer prevention trials have shown a significant benefit for 5-α-reductase inhibitors. However, this class of agents was also associated with increased detection of high-grade prostate cancer. Another large, Phase III prostate cancer prevention trial showed no benefit for either selenium or vitamin E, given individually or in combination; in fact, a significant increase in prostate cancer was observed among men randomized to the vitamin E alone arm.

SUMMARY

A number of early phase trials and three definitive Phase III trials have been conducted in the field of prostate cancer prevention over the past decade. Although a great deal has been learned from these studies, significant work remains to be done to fully realize the potential of chemoprevention in this disease.

Small renal masses: surgery or surveillance

The incidence of kidney cancer has been rising over the past two decades, especially in cases in which the disease is localized and small in size (<4 cm). This rise is mainly due to the widespread use of routine abdominal imaging such as ultrasonography, computed tomography, and magnetic resonance imaging. Early detection was initially heralded as an opportunity to cure an otherwise lethal disease. However, despite increasing rates of renal surgery in parallel to this trend, mortality rates from renal cell carcinoma have remained relatively unchanged. Moreover, data suggest that a substantial proportion of small renal masses are benign. As a result, the management of small renal masses has continued to evolve along two basic themes: it has become less radical and less invasive. These shifts are in part a reflection of an improved understanding that the biology of incidentally discovered renal cell carcinoma may be more indolent than previously thought. However, not all small renal masses are indolent, and de novo metastatic disease can develop at the initial presentation. Therefore, it is with this background of clinical uncertainty and biological heterogeneity that clinicians must interpret the benefits and disadvantages of various clinical approaches to small renal masses.

Urinary TMPRSS2:ERG and PCA3 in an active surveillance cohort: results from a baseline analysis in the Canary Prostate Active Surveillance Study

PURPOSE

Active surveillance is used to manage low-risk prostate cancer. Both PCA3 and TMPRSS2:ERG are promising biomarkers that may be associated with aggressive disease. This study examines the correlation of these biomarkers with higher cancer volume and grade determined at the time of biopsy in an active surveillance cohort.

EXPERIMENTAL DESIGN

Urine was collected after digital rectal examination prospectively as part of the multi-institutional Canary Prostate Active Surveillance Study (PASS). PCA3 and TMPRSS2:ERG levels were analyzed in urine collected at study entry. Biomarker scores were correlated to clinical and pathologic variables.

RESULTS

In 387 men, both PCA3 and TMPRSS2:ERG scores were significantly associated with higher volume disease. For a negative repeat biopsy, and 1% to 10%, 11% to 33%, 34% or more positive cores, median PCA3, and TMPRSS2:ERG scores increased incrementally (P < 0.005). Both PCA3 and TMPRSS2:ERG scores were also significantly associated with the presence of high-grade disease. For a negative repeat biopsy, Gleason 6 and Gleason ≥7 cancers, the median PCA3, and TMPRSS2:ERG scores also increased incrementally (P = 0.02 and P = 0.001, respectively). Using the marker scores as continuous variables, the ORs for a biopsy in which cancer was detected versus a negative repeat biopsy (ref) on modeling was 1.41 (95% CI: 1.07-1.85), P = 0.01 for PCA3 and 1.28 (95% CI: 1.10-1.49), P = 0.001 for TMPRSS2:ERG.

CONCLUSIONS

For men on active surveillance, both PCA3 and TMPRSS2:ERG seem to stratify the risk of having aggressive cancer as defined by tumor volume or Gleason score.

Prostate cancer: can multiparametric MR imaging help identify patients who are candidates for active surveillance?

PURPOSE

To determine whether multiparametric magnetic resonance (MR) imaging can help identify patients with prostate cancer who would most appropriately be candidates for active surveillance (AS) according to current guidelines and to compare the results with those of conventional clinical assessment scoring systems, including the D'Amico, Epstein, and Cancer of the Prostate Risk Assessment (CAPRA) systems, on the basis of findings at prostatectomy.

MATERIALS AND METHODS

This institutional review board-approved HIPAA-compliant retrospectively designed study included 133 patients (mean age, 59.3 years) with a mean prostate-specific antigen level of 6.73 ng/mL (median, 4.39 ng/mL) who underwent multiparametric MR imaging at 3.0 T before radical prostatectomy. Informed consent was obtained from all patients. Patients were then retrospectively classified as to whether they would have met AS eligibility criteria or were better served by surgery. AS eligibility criteria for prostatectomy specimens were a dominant tumor smaller than 0.5 mL without Gleason 4 or 5 patterns or extracapsular or seminal vesicle invasion. Conventional clinical assessment scores (the D'Amico, Epstein, and CAPRA scoring systems) were compared with multiparametric MR imaging findings for predicting AS candidates. The level of significance of difference between scoring systems was determined by using the χ(2) test for categoric variables with the level of significance set at P < .05.

RESULTS

Among 133 patients, 14 were eligible for AS on the basis of prostatectomy results. The sensitivity, positive predictive value (PPV), and overall accuracy, respectively, were 93%, 25%, and 70% for the D'Amico system, 64%, 45%, and 88% for the Epstein criteria, and 93%, 20%, and 59% for the CAPRA scoring system for predicting AS candidates (P < .005 for all, χ(2) test), while multiparametric MR imaging had a sensitivity of 93%, a PPV of 57%, and an overall accuracy of 92% (P < .005).

CONCLUSION

Multiparametric MR imaging provides useful additional information to existing clinicopathologic scoring systems of prostate cancer and improves the assignment of treatment (eg, AS or active treatment).

Medium-term outcomes of active surveillance for localised prostate cancer

BACKGROUND

Active surveillance (AS) aims to allow men with favourable-risk, localised prostate cancer to avoid unnecessary treatment.

OBJECTIVE

To describe the clinical outcomes of a prospective study of AS.

DESIGN, SETTING, AND PARTICIPANTS

A single-centre, prospective cohort study. Eligibility criteria included histologically proven prostate adenocarcinoma, age 50-80 yr, stage T1/T2, prostate-specific antigen level (PSA) <15 ng/ml, Gleason score (GS) ≤ 3+3 (GS ≤ 3+4 if aged >65 yr), and percent positive biopsy cores (PPC) ≤ 50%.

INTERVENTION

Patients were assessed by serum PSA level, and digital rectal examination at 3-mo intervals in year 1, 4-mo intervals in year 2, and at 6-mo intervals thereafter. Transrectal ultrasound-guided prostate biopsy was performed after 18-24 mo and every 2 yr thereafter. Treatment was recommended for PSA velocity (PSAV) >1 ng/ml per year or adverse histology, defined as GS ≥ 4+3 or PPC >50%.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcomes described, using Kaplan-Meier methods, were rate of adverse histology on repeat biopsy, freedom from treatment, biochemical control after deferred treatment, and overall survival. Analyses using Cox regression were performed to determine predictors of deferred treatment and adverse histology.

RESULTS AND LIMITATIONS

The study enrolled 471 eligible patients from 2002 to 2011. Median age was 66 yr and median initial PSA value was 6.4 ng/ml. Eighty-eight percent of patients had T1 disease and 93% had GS ≤ 3+3. At median follow-up of 5.7 yr, the 5-yr rate of adverse histology and treatment-free probability was 22% (95% confidence interval [CI], 16-29%) and 70% (95% CI, 65-75%), respectively. There were two deaths from prostate cancer. Predictors of time to adverse histology were GS 7, PSAV >1 ng/ml per year, low ratio of free PSA to total PSA, and PPC >25%. Longer follow-up is needed to confirm the safety of this strategy.

CONCLUSIONS

This study demonstrates satisfactory medium-term outcomes for AS in selected men with localised prostate cancer.

Preoperative predictors of pathologic stage T2a and pathologic Gleason score ≤ 6 in men with clinical low-risk prostate cancer treated with radical prostatectomy: reference for active surveillance

To assess preoperative parameters that may be predictive of pathologic stage T2a (pT2a) and pathologic Gleason score (pGS) ≤ 6 disease in low-risk prostate cancer patients considering active surveillance. A cohort of 1,495 men with low-risk prostate cancer between 1993 and 2009 was utilized. Preoperative assessment focused on patient age, race, diagnostic PSA level, clinical stage, diagnostic biopsy Gleason score, and prostate cancer laterality. Kaplan-Meier curves and a Cox regression model were used for analysis of PSA recurrence. Preoperative parameters were analyzed by univariate and multivariate logistic regression methods. Of 1,495 patients, 187 (12.5 %) were identified with pT2a and pGS ≤ 6 disease. Of the 187 men with pT2a and pGS ≤ 6 disease, only 6 (3.2 %) cases had PSA recurrence. Kaplan-Meier PSA recurrence-free survival curves identified a difference between prostate cancers with pT2a and pGS ≤ 6 and prostate cancers with >pT2a or pGS ≥ 7 disease (p = 0.002). Only biopsy tumor unilaterality (OR, 10.452; p ≤ 0.001) and low diagnostic PSA levels (OR, 0.887; p = 0.003) were independent predictors of prostate cancers with pT2a and pGS ≤ 6 disease on univariate and multivariate logistic regression. Biopsy tumor unilaterality and low diagnostic PSA levels are the independent predictors of pT2a and pGS ≤ 6 disease in low-risk prostate cancer patients. Unilateral cancer by prostate biopsy and low diagnostic PSA level may be the reference to improving the selection of appropriate candidates for active surveillance within a low-risk prostate cancer cohort.

Factors influencing patients' acceptance and adherence to active surveillance

Clinical decision making in localized prostate cancer is a complicated, multidimensional process in which men often consider their own personal preferences, the advice of their healthcare providers, the opinions of their family and friends, and outside information sources. They synthesize all of this within the framework of their own unique socioeconomic situation, their social support network, and their preconceived impressions of their health and the health-care system. This is particularly germane when considering factors that influence a patient's acceptance of and adherence to active surveillance (AS). We propose a conceptual framework based on a previously described systematic-heuristic theoretical model of decision making in this setting. We identify a number of factors that patients systematically prioritize when considering AS. These include desire for cancer control or cure, age at diagnosis, and concern regarding side effects of treatment. The way patients value these factors and effectively decide on treatment is influenced by more heuristic factors, including physician recommendation, opinion of friends and family members, and overall decision uncertainty. These heuristic factors also play an important role in adherence when a patient elects AS. Finally, some of the factors, particularly the heuristic ones, are potentially modifiable and may serve as targets for future interventions to increase acceptance of and adherence to AS.

The current status of active surveillance for prostate cancer

The occurrence of low-risk, localized prostate cancer (PCa) has increased in the prostate-specific antigen era. A significant amount of low-risk PCas progress slowly and may not impact patient survival. Thus, these patients may be subjected to unnecessary interventions that result in physical and psychological complications. The active surveillance (AS) protocol has been used over the few past decades. It was designed so that patients with low-risk PCa can be monitored for a period of time, during which they are free from complication of interventions, and can be treated with curative intention on evidence of disease progression. Institutions have developed different selection criteria and follow-up schedules for suitable patients with PCa. Recently, long-term data have emerged suggesting that AS is a reasonable option for appropriately selected patients with low-risk PCa who have a life expectancy of < 10 years. Subsequently, the AS protocol has been recognized by various guidelines as part of the treatment strategy for PCa. However, the challenges that remain for AS are the risk of under-staging of PCa and the low uptake and high attrition rate of AS, and questions remain regarding its long-term efficacy. Recent advances in AS for PCa, such as better imaging modality, combining AS with limited local therapy, as well as the role of AS in association with chemoprevention, are discussed.

International multicentre study examining selection criteria for active surveillance in men undergoing radical prostatectomy

Background:

The controversies concerning possible overtreatment of prostate cancer, highlighted by debate over PSA screening, have highlighted active surveillance (AS) as an alternative management option for appropriate men. Regional differences in the underlying prevalence of PSA testing may alter the pre-test probability for high-risk disease, which can potentially interfere with the performance of selection criteria for AS. In a multicentre study from three different countries, we examine men who were initially suitable for AS according to the Toronto and Prostate Cancer Research International: Active Surveillance (PRIAS) criteria, that underwent radical prostatectomy (RP) in regards to:1.the proportion of pathological reclassification(Gleason score ⩾7, ⩾pT3 disease),2.predictors of high-risk disease,3.create a predictive model to assist with selection of men suitable for AS.

Methods:

From three centres in the United Kingdom, Canada and Australia, data on men who underwent RP were retrospectively reviewed (n=2329). Multivariable logistic regression was performed to identify predictors of high-risk disease. A nomogram was generated by logistic regression analysis, and performance characterised by receiver operating characteristic curves.

Results:

For men suitable for AS according to the Toronto (n=800) and PRIAS (410) criteria, the rates for upgrading were 50.6, 42.7%, and upstaging 17.6, 12.4%, respectively. Significant predictors of high-risk disease were:•Toronto criteria: increasing age, cT2 disease, centre of diagnosis and number of positive cores.•PRIAS criteria: increasing PSA and cT2 disease.Cambridge had a high pT3a rate (26 vs 12%). To assist selection of men in the United Kingdom for AS, from the Cambridge data, we generated a nomogram predicting high-risk features in patients who meet the Toronto criteria (AUC of 0.72).

Conclusion:

The proportion of pathological reclassification in our cohort was higher than previously reported. Care must be used when applying the AS criteria generated from one population to another. With more stringent selection criteria, there is less reclassification but also fewer men who may benefit from AS.

Magnetic resonance imaging for predicting prostate biopsy findings in patients considered for active surveillance of clinically low risk prostate cancer

PURPOSE

A barrier to the acceptance of active surveillance for men with prostate cancer is the risk of underestimating the cancer burden on initial biopsy. We assessed the value of endorectal magnetic resonance imaging in predicting upgrading on confirmatory biopsy in men with low risk prostate cancer.

MATERIALS AND METHODS

A total of 388 consecutive men (mean age 60.6 years, range 33 to 89) with clinically low risk prostate cancer (initial biopsy Gleason score 6 or less, prostate specific antigen less than 10 ng/ml, clinical stage T2a or less) underwent endorectal magnetic resonance imaging before confirmatory biopsy. Three radiologists independently and retrospectively scored tumor visibility on endorectal magnetic resonance imaging using a 5-point scale (1-definitely no tumor to 5-definitely tumor). Inter-reader agreement was assessed with weighted kappa statistics. Associations between magnetic resonance imaging scores and confirmatory biopsy findings were evaluated using measures of diagnostic performance and multivariate logistic regression.

RESULTS

On confirmatory biopsy, Gleason score was upgraded in 79 of 388 (20%) patients. Magnetic resonance imaging scores of 2 or less had a high negative predictive value (0.96-1.0) and specificity (0.95-1.0) for upgrading on confirmatory biopsy. A magnetic resonance imaging score of 5 was highly sensitive for upgrading on confirmatory biopsy (0.87-0.98). At multivariate analysis patients with higher magnetic resonance imaging scores were more likely to have disease upgraded on confirmatory biopsy (odds ratio 2.16-3.97). Inter-reader agreement and diagnostic performance were higher for the more experienced readers (kappa 0.41-0.61, AUC 0.76-0.79) than for the least experienced reader (kappa 0.15-0.39, AUC 0.61-0.69). Magnetic resonance imaging performed similarly in predicting low risk and very low risk (Gleason score 6, less than 3 positive cores, less than 50% involvement in all cores) prostate cancer.

CONCLUSIONS

Adding endorectal magnetic resonance imaging to the initial clinical evaluation of men with clinically low risk prostate cancer helps predict findings on confirmatory biopsy and assess eligibility for active surveillance.

Long-term radical prostatectomy outcomes among participants from the European Randomized Study of Screening for Prostate Cancer (ERSPC) Rotterdam

Study Type--Therapy (cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Radical prostatectomy was previously shown to improve long-term outcomes among men with clinically-detected prostate cancer. Our data suggests that radical prostatectomy is also associated with improved outcomes in men with screen-detected prostate cancer.

OBJECTIVE

• To examine the long-term outcomes of radical prostatectomy (RP) among men diagnosed with prostate cancer from the screening and control arms of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC).

PATIENTS AND METHODS

• Among 42,376 men randomised during the period of the first round of the trial (1993-1999), 1151 and 210 in the screening and control arms were diagnosed with prostate cancer, respectively. • Of these men, 420 (36.5%) screen-detected and 54 (25.7%) controls underwent RP with long-term follow-up data (median follow-up 9.9 years). • Progression-free (PFS), metastasis-free (MFS) and cancer-specific survival (CSS) rates were examined, and multivariable Cox proportional hazards models were used to determine whether screen-detected (vs control) was associated with RP outcomes after adjusting for standard predictors.

RESULTS

• RP cases from the screening and control arms had statistically similar clinical stage and biopsy Gleason score, although screen-detected cases had significantly lower prostate-specific antigen (PSA) levels at diagnosis. • Men from the screening arm had a significantly higher PFS (P = 0.003), MFS (P < 0.001) and CSS (P = 0.048). • In multivariable models adjusting for age, PSA level, clinical stage, and biopsy Gleason score, the screening group had a significantly lower risk of biochemical recurrence (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.23-0.83, P = 0.011) and metastasis (HR 0.18, 95% CI 0.06-0.59, P = 0.005). • Additionally adjusting for tumour volume and other RP pathology features, there was no longer a significant difference in biochemical recurrence between the screening and control arms. • Limitations of the present study include lead-time bias and non-randomised treatment selection.

CONCLUSIONS

• After RP, screen-detected cases had significantly improved PFS, MFS and CSS compared with controls within the available follow-up time. • The screening arm remained significantly associated with lower rates of biochemical recurrence and metastasis after adjusting for other preoperative variables. • However, considering also RP pathology, the improved outcomes in the screening group appeared to be mediated by a significantly lower tumour volume.