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

PSA-based prostate cancer screening: the role of active surveillance and informed and shared decision making

Since the first publication describing the identification of prostate-specific antigen (PSA) in the 1960s, much progress has been made. The PSA test changed from being initially a monitoring tool to being also used as a diagnostic tool. Over time, the test has been heavily debated due to its lack of sensitivity and specificity. However, up to now the PSA test is still the only biomarker for the detection and monitoring of prostate cancer. PSA-based screening for prostate cancer is associated with a high proportion of unnecessary testing and overdiagnosis with subsequent overtreatment. In the early years of screening for prostate cancer, high rates of uptake were very important. However, over time the opinion on PSA-based screening has shifted towards the notion of informed choice. Nowadays, it is thought to be unethical to screen men without them being aware of the pros and cons of PSA testing, as well as the fact that an informed choice is related to better patient outcomes. Now, as the results of three major screening studies have been presented and the downsides of screening are becoming better understood, informed choice is becoming more relevant.

Acceptance and durability of surveillance as a management choice in men with screen-detected, low-risk prostate cancer: improved outcomes with stringent enrollment criteria

OBJECTIVE

To analyze the acceptance rate and durability of surveillance among contemporary men with low-risk prostate cancer managed at a large, US academic institution.

METHODS

Patients with low-risk parameters on initial and repeat biopsy were offered surveillance regardless of age. Regular clinical evaluation and repeat prostate biopsy were recommended every 1-2 years, and intervention was recommended based on adverse clinical and pathologic parameters on follow-up. Acceptance rate of active surveillance, freedom from intervention, and freedom from recommended intervention were measured.

RESULTS AND LIMITATIONS

Of 202 low-risk patients, 86 (43%) chose immediate treatment and 116 (57%) underwent repeat biopsy for consideration of surveillance. Intervention was recommended after initial repeat biopsy in 27 (23%) men because of higher-risk features, leaving a total of 89 men on surveillance. Over a median follow-up of 33 months, 16 men were ultimately treated and 8 were recommended to undergo treatment because of adverse clinical features on subsequent evaluations. Of the men on surveillance, the 3-year freedom from intervention and freedom from recommended intervention was 87% (95% CI, 78-93) and 93% (95% CI, 85-97), respectively.

CONCLUSIONS

Acceptance of surveillance (57%) in low-risk patients in this series is substantially higher than previous reports, and approximately one-third of these patients are ultimately managed by surveillance using stringent criteria. The risk of reclassification to a more aggressive cancer over short-term follow-up in appropriately selected patients is low.

ProPSA and diagnostic biopsy tissue DNA content combination improves accuracy to predict need for prostate cancer treatment among men enrolled in an active surveillance program

OBJECTIVES

To assess a novel application of the Prostate Health Index (phi) and biopsy tissue DNA content in benign-adjacent and cancer areas to predict which patients would eventually require treatment of prostate cancer in the Proactive Surveillance cohort.

METHODS

We identified 71 men who had had serum and biopsy tissue from their diagnosis banked and available for the present study. Of the 71 patients, 39 had developed unfavorable biopsy findings and 32 had maintained favorable biopsy status during surveillance. The serum total prostate-specific antigen (tPSA), free PSA (fPSA) and [-2]proPSA were measured using the Beckman Coulter immunoassay. The DNA content measurements of Feulgen-stained biopsy sections were performed using the AutoCyte imaging system.

RESULTS

The ratio of phi was significantly greater (37.23 ± 15.76 vs 30.60 ± 12.28; P = .03) in men who ultimately had unfavorable biopsy findings. The serum phi ratio (P = .003), [-2]proPSA/%fPSA (P = .004), biopsy tissue DNA content (ie, benign-adjacent excess of optical density, P = .019; and cancer area standard deviation of optical density, P = .002) were significant predictors of unfavorable biopsy conversion on Cox regression analysis. However, phi and [-2]proPSA/%fPSA showed a highly significant correlation (rho = 0.927, P < .0001) and no difference in accuracy (c-index, 0.6247 vs 0.6158; P = .704) for unfavorable biopsy conversion prediction. Furthermore, phi and [-2]proPSA/%fPSA remained significant (P = .047 and P = .036, respectively) in the multivariate models and, combined with the biopsy tissue DNA content, showed improvement in the predictive accuracy (c-index, 0.6908 and 0.6884, respectively) for unfavorable biopsy conversion.

CONCLUSIONS

The Prostate Health Index to proPSA/%fPSA, combined with biopsy tissue DNA content, improved the accuracy to about 70% to predict unfavorable biopsy conversion at the annual surveillance biopsy examination among men enrolled in an Active Surveillance program.

Impact of 5α-reductase inhibitors on men followed by active surveillance for prostate cancer

BACKGROUND

In two large randomized controlled trials, 5α-reductase inhibitors (5-ARIs) were shown to prevent prostate cancer. No prior work had shown the effect of 5-ARIs on those already diagnosed with low-risk prostate cancer.

OBJECTIVE

Our aim was to determine the effect of 5-ARIs on pathologic progression in men on active surveillance.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a single-institution retrospective cohort study comparing men taking a 5-ARI versus no 5-ARI while on active surveillance for prostate cancer.

MEASUREMENTS

Pathologic progression was evaluated and defined as Gleason score >6, maximum core involvement >50%, or more than three cores positive on a follow-up prostate biopsy. Kaplan-Meier analyses were conducted along with multivariable Cox proportional hazard regression modeling for predictors of pathologic progression.

RESULTS AND LIMITATIONS

A total of 288 men on active surveillance met the inclusion criteria. The median follow-up was 38.5 mo (interquartile range: 23.6-59.4) with 93 men (32%) experiencing pathologic progression and 96 men (33%) abandoning active surveillance. Men taking a 5-ARI experienced a lower rate of pathologic progression (18.6% vs 36.7%; p=0.004) and were less likely to abandon active surveillance (20% vs 37.6%; p=0.006). On multivariable Cox proportional hazards analysis, lack of 5-ARI use was most strongly associated with pathologic progression (hazard ratio: 2.91; 95% confidence interval, 1.5-5.6). The main study limitation was the retrospective design and variable duration of 5-ARI therapy.

CONCLUSIONS

The 5-ARIs were associated with a significantly lower rate of pathologic progression and abandonment of active surveillance.

Risk stratification and validation of prostate specific antigen density as independent predictor of progression in men with low risk prostate cancer during active surveillance

PURPOSE

We assessed risk stratification in patients with low grade prostate cancer managed by active surveillance using a 20-core saturation biopsy technique.

MATERIALS AND METHODS

A total of 135 consecutive patients with low risk prostate cancer were prospectively entered in an active surveillance program in a 10-year period. The study entrance requirement and progression definition followed Epstein criteria using only pathological parameters, ie fewer than 3 positive cores, Gleason score 6 or less and 50% or less of any single core involved. All patients were monitored by restaging 20-core saturation biopsy every 12 to 18 months. A total of 120 patients with at least 1 rebiopsy form the basis of this report.

RESULTS

Of the cohort 30% progressed during a median of 2.4 years. Three multivariate analyses were performed. The first analysis used variables only at diagnosis biopsy and revealed that prostate specific antigen density greater than 0.08 ng/ml/cc and prostate cancer family history were significant predictors of progression. When combined in a 3-level risk factor score, they were significant (p = 0.003). The second multivariate analysis considered changes in characteristics between diagnosis biopsy and first rebiopsy. Prostate specific antigen velocity along with prostate specific antigen density and family history highly predicted progression according to a 4-level risk factor score (p <0.0001). The third multivariate analysis validated the previously reported prostate specific antigen density cutoff of 0.08 ng/ml/cc at first rebiopsy as a significant predictor of subsequent progression (HR 3.16, 95% CI 1.12, 8.93; p = 0.03).

CONCLUSIONS

Risk factor stratification can be used to significantly predict the outcome in patients on active surveillance. Prostate specific antigen density 0.08 ng/ml/cc at first rebiopsy was validated as a significant predictor of subsequent progression.

Role of prostate specific antigen and immediate confirmatory biopsy in predicting progression during active surveillance for low risk prostate cancer

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 confirmatory 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 confirmatory biopsy to better assess the risk of progression.

Active surveillance for favorable-risk prostate cancer: a short review

Active surveillance is becoming a more widely accepted management strategy in men with low-risk localized prostate cancer. This is in recognition of the knowledge that most men with such cancer are likely to die from other causes. The obvious benefits of active surveillance are reduced morbidity by delaying or avoiding radical gland therapy. These advantages should be balanced against appropriate selection criteria and triggers for moving to radical therapy while on active surveillance. The optimal method by which to identify the small number of men who will progress by use of clinical, biopsy, and imaging data is yet to be defined. Nevertheless, active surveillance is an appealing management option in selected men with prostate cancer and represents a solution to the significant problem of the overdiagnosis of clinically insignificant disease that accompanies prostate-specific antigen (PSA) screening.

Prostate cancer as a model for tumour immunotherapy

Advances in basic immunology have led to an improved understanding of the interactions between the immune system and tumours, generating renewed interest in approaches that aim to treat cancer immunologically. As clinical and preclinical studies of tumour immunotherapy illustrate several immunological principles, a review of these data is broadly instructive and is particularly timely now that several agents are beginning to show evidence of efficacy. This is especially relevant in the case of prostate cancer, as recent approval of sipuleucel-T by the US Food and Drug Administration marks the first antigen-specific immunotherapy approved for cancer treatment. Although this Review focuses on immunotherapy for prostate cancer, the principles discussed are applicable to many tumour types, and the approaches discussed are highlighted in that context.

Nuclear roundness variance predicts prostate cancer progression, metastasis, and death: A prospective evaluation with up to 25 years of follow-up after radical prostatectomy

BACKGROUND

Nuclear structure is often altered in cancer due to spatial rearrangements of chromatin organization via activation of oncogenes and other chromatin remodeling genes. Therefore, we evaluated the prognostic value of nuclear roundness variance (NRV) for prostate cancer (PCa) progression, metastasis and PCa-specific death free survivals in a cohort of 116 men after radical prostatectomy (RP).

METHOD

NRV was calculated for each case using the variance of the nuclear roundness from approximately 150 nuclei captured at a magnification of 2,440x for each case in 1992-1993. $${\rm Nuclear}\,{\rm roundness} = {{{\rm Radius}({\rm circumference})} \over {{\rm radius}({\rm area})}} = {R \over r} = {{P/2\pi } \over {\sqrt {A/\pi } }}$$ NRV data were merged with clinical, pathologic, and follow-up data for all patients in 2009. Cox proportional hazards regression and Kaplan-Meier plots were employed to analyze the data.

RESULTS

Median follow-up time after RP for all patients was 19 years (range: 1-25 years, mean: 17 years), with approximately 92% (107/116), 71% (82/116), and 47% (55/116) patients having >or=10, 15, and 20 years of follow-up, respectively. NRV was the most significant parameter for prediction of all three outcomes and its concordance-index (C-Index) increased from progression (0.7080) to metastasis (0.7332) to PCa-specific death (0.8090) free survival predictions. Of note, NRV C-Index was significantly higher compared to Gleason Score C-Index for metastasis (0.7332 vs. 0.6046; P = 0.027) and PCa-specific death (0.8090 vs. 0.6336; P = 0.004) free survival predictions. However, the difference between NRV and Gleason Score C-Indexes was not statistically significant for progression free survival prediction (0.7080 vs. 0.6463; P = 0.106).

CONCLUSION

NRV is valuable nuclear structural feature that exceeds Gleason score to predict an aggressive phenotype of PCa.

Preoperative Clinical and Pathological Characteristics of pT0 Prostate Cancer in Radical Prostatectomy

Purpose

To analyze the preoperative clinical and pathological characteristics of patients with pT0 prostate cancer.

Materials and Methods

We retrospectively reviewed the records of 702 patients who underwent radical prostatectomy (RP) at our institution between January 2004 and July 2008 for clinically localized prostate cancer. If there was no evidence of residual tumor in the pathological specimen of the prostate, a patient was staged as pT0. Patients with pT0 disease were compared with a control group of patients who were operated on during the same period.

Results

Overall, 9 (1.3%) patients were staged as pT0 on the pathologic examination. Significant differences were observed between the pT0 group and the control patients in the biopsy Gleason score (p=0.004), the number of positive cores on biopsy (p=0.018), the tumor length of positive cores (p<0.001), and prostate volume (p=0.015). Cutoff values predictive of pT0 tumor status were defined as a biopsy Gleason score sum ≤6, 2 or fewer positive biopsy cores, tumor length on biopsy ≤2 mm, and prostate volume >30 cm³. Whereas 8 of the 9 (88.9%) pT0 patients showed all of these characteristics, only 55 of the 693 (7.9%) control patients fulfilled the criteria. The combination suggested above afforded a sensitivity of 88.8% and a specificity of 92.1% for the prediction of pT0 status.

Conclusions

The frequency of pT0 prostate cancer seen on RP was 1.3%. A combination of clinicopathological features, incorporating a biopsy Gleason score, the number of positive biopsy cores, tumor length on biopsy, and prostate volume, was useful to predict pT0 stage on RP.

Outcomes in localized prostate cancer: National Prostate Cancer Register of Sweden follow-up study

Background

Treatment for localized prostate cancer remains controversial. To our knowledge, there are no outcome studies from contemporary population-based cohorts that include data on stage, Gleason score, and serum levels of prostate-specific antigen (PSA).

Methods

In the National Prostate Cancer Register of Sweden Follow-up Study, a nationwide cohort, we identified 6849 patients aged 70 years or younger. Inclusion criteria were diagnosis with local clinical stage T1–2 prostate cancer from January 1, 1997, through December 31, 2002, a Gleason score of 7 or less, a serum PSA level of less than 20 ng/mL, and treatment with surveillance (including active surveillance and watchful waiting, n = 2021) or curative intent (including radical prostatectomy, n = 3399, and radiation therapy, n = 1429). Among the 6849 patients, 2686 had low-risk prostate cancer (ie, clinical stage T1, Gleason score 2-6, and serum PSA level of <10 ng/mL). The study cohort was linked to the Cause of Death Register, and cumulative incidence of death from prostate cancer and competing causes was calculated.

Results

For the combination of low- and intermediate-risk prostate cancers, calculated cumulative 10-year prostate cancer–specific mortality was 3.6% (95% confidence interval [CI] = 2.7% to 4.8%) in the surveillance group and 2.7% (95% CI = 2.1% to 3.45) in the curative intent group. For those with low-risk disease, the corresponding values were 2.4% (95% CI = 1.2% to 4.1%) among the 1085 patients in the surveillance group and 0.7% (95% CI = 0.3% to 1.4%) among the 1601 patients in the curative intent group. The 10-year risk of dying from competing causes was 19.2% (95% CI = 17.2% to 21.3%) in the surveillance group and 10.2% (95% CI = 9.0% to 11.4%) in the curative intent group.

Conclusion

A 10-year prostate cancer–specific mortality of 2.4% among patients with low-risk prostate cancer in the surveillance group indicates that surveillance may be a suitable treatment option for many patients with low-risk disease.

Prostate-Specific Antigen Kinetics During Follow-Up Are an Unreliable Trigger for Intervention in a Prostate Cancer Surveillance Program

Purpose

To assess the predictive ability of prostate-specific antigen (PSA) velocity (PSAV) and doubling time (PSADT) for biopsy progression and adverse pathology at prostatectomy among men with low-risk prostate cancer enrolled on an active-surveillance program.

Methods

We evaluated 290 men who met criteria for active surveillance (ie, PSA density < 0.15 ng/mL/cm3 and Gleason score ≤ 6 with no pattern ≥ 4, involving ≤ 2 cores with cancer, and ≤ 50% involvement of any core by cancer) with two or more serial PSA measurements after diagnosis from 1994 to 2008. Follow-up included twice-yearly digital rectal exam and PSA measurements and yearly surveillance biopsy. Treatment was recommended for biopsy progression (ie, Gleason score ≥ 7, or > 2 positive cores, or > 50% core involvement). Sensitivity and specificity of postdiagnostic PSAV and PSADT were explored by using receiver operating characteristic (ROC) analysis.

Results

Overall, 188 (65%) men remained on active surveillance, and 102 (35%) developed biopsy progression at a median follow-up of 2.9 years. PSADT was not significantly associated with subsequent adverse biopsy findings (P = .83), and PSAV was marginally significant (P = .06). No PSAV or PSADT cut point had both high sensitivity and specificity (area under the curve, 0.61 and 0.59, respectively) for biopsy progression. In those who eventually underwent radical prostatectomy, PSAV (P = .79) and PSADT (P = .87) were not associated with the presence of unfavorable surgical pathology.

Conclusion

Postdiagnostic PSA kinetics do not reliably predict adverse pathology and should not be used to replace annual surveillance biopsy for monitoring men on active surveillance.

Treatment of localized prostate cancer: when is active surveillance appropriate?

Testing for prostate-specific antigen (PSA) has caused a dramatic increase in the incidence of prostate cancer during the past two decades. Many cancers identified by repeated PSA testing are small volume, low-grade lesions that pose little threat of progression over 15-20 years. Data from a recently reported randomized trial indicate that as many as 48 men must undergo treatment to prevent one prostate cancer-related death. Unfortunately, no test is currently available that can identify those men who have clinically significant disease. Men least likely to experience disease progression are men who harbor tumors with a Gleason score of 6 involving 2 needle cores or less; these men may want to consider active surveillance as their initial treatment option. Researchers have followed over 2,500 men on active surveillance protocols (over 200 men have been followed for >10 years). To date, prostate cancer-specific survival is over 99%. About 25% of men enrolled in active surveillance programs have abandoned this approach because of concerns about disease progression. For men harboring tumors with a Gleason score >7, data from two recently reported Swedish trials suggest lower prostate cancer-related mortality for those men receiving either surgery or radiation.

Outcomes after radical prostatectomy among men who are candidates for active surveillance: results from the SEARCH database

OBJECTIVE

We sought to evaluate outcomes after radical prostatectomy among men with low-risk prostate cancer who would be candidates for active surveillance.

METHODS

Using the Shared Equal Access Regional Cancer Hospital (SEARCH) database of men treated with radical prostatectomy at multiple equal-access medical centers between 1988 and 2007, 398 of 2062 men (19%) met our criteria for potential active surveillance: clinical stage T1c or T2a, prostate-specific antigen (PSA) <10 ng/mL, Gleason sum ≤6, and no more than 1 or 2 positive cores on at least a sextant biopsy. We examined the risk of adverse pathology, biochemical progression, and PSA doubling time (PSADT) at the time of recurrence. We used a Cox proportional hazards model to determine the significant predictors of PSA progression.

RESULTS

Of the men with low-risk prostate cancer, 85% had organ-confined disease, only 2% had seminal vesicle invasion, and no patient had lymph node metastasis. The 5- and 10 year PSA-free survival rates were 81% (95% CI: 76-86%) and 66% (95% CI: 54-76%). On multivariate analysis, older age (P = .005), Agent Orange exposure (P = .02), and obesity (P = .03) were all significantly associated with biochemical failure. Mean and median PSADT among men who experienced recurrence were 37 and 20 months. Only 3 patients experienced recurrence with PSADT < 9 months.

CONCLUSIONS

Most men with low-risk prostate cancer treated with radical prostatectomy experience long-term PSA control. Those who did experience recurrence often did so with a long PSADT. Consistent with prior SEARCH database reports, older age, Agent Orange exposure, and obesity increased the risk of recurrence.

Low dose, alternating electric current inhibits growth of prostate cancer

BACKGROUND

A number of minimally invasive technologies exist for the treatment of prostate cancer (CaP), each with their associated morbidities. We sought to test the efficacy of low dose alternating electric current (LDAEC) to inhibit CaP growth in a preclinical setting and determine its effect on normal tissue.

METHODS

In the first study, two power settings, 15 or 25 mA of current, and two treatment times, 15 or 60 min, were evaluated in C4-2B CaP xenografts. In the second study, power was regulated to maintain an intra-tumoral temperature of <or=45 degrees C in C4-2B and LuCaP 35 tumors. In both studies, tumor volume, serum PSA levels, survival and histology were analyzed. In a third study, LDAEC was applied to mice hamstrings with evaluation of gait and histology.

RESULTS

The most effective tumor volume reduction in the first study was seen with tumors treated with 25 mA for 15 min (62 +/- 9.4% decrease, P = 0.001). Longer treatment time did not enhance treatment effect. Using 45 degrees C to govern delivery of LDAEC resulted in a near 100% reduction in tumor volume in 8/10 mice with C4-2B tumors (P < 0.001) with similar inhibition of LuCaP 35 tumors (P = 0.01). This treatment, although resulting in skeletal muscle necrosis, did not affect nerves, smooth muscle and blood vessels.

CONCLUSION

LDAEC demonstrates efficacy against C4-2B and LuCaP 35 CaP xenografts while causing no harm to nerves and blood vessels. These results warrant further investigations into the use of LDAEC as a treatment for CaP.

Focal therapy for prostate cancer: possibilities and limitations

CONTEXT

A significant proportion of patients diagnosed with prostate cancer have well-differentiated, low-volume tumors at minimal risk of impacting their quality of life or longevity. The selection of a treatment strategy, among the multitude of options, has enormous implications for individuals and health care systems.

OBJECTIVE

Our aim was to review the rationale, patient selection criteria, diagnostic imaging, biopsy schemes, and treatment modalities available for the focal therapy of localized prostate cancer. We gave particular emphasis to the conceptual possibilities and limitations.

EVIDENCE ACQUISITION

A National Center for Biotechnology Information PubMed search (www.pubmed.gov) was performed from 1995 to 2009 using medical subject headings "focal therapy" or "ablative" and "prostate cancer." Additional articles were extracted based on recommendations from an expert panel of authors.

EVIDENCE SYNTHESIS

Focal therapy of the prostate in patients with low-risk cancer characteristics is a proposed treatment approach in development that aims to eradicate all known foci of cancer while minimizing damage to adjacent structures necessary for the preservation of urinary, sexual, and bowel function. Conceptually, focal therapy has the potential to minimize treatment-related toxicity without compromising cancer-specific outcome. Limitations include the inability to stage or grade the cancer(s) accurately, suboptimal imaging capabilities, uncertainty regarding the natural history of untreated cancer foci, challenges with posttreatment monitoring, and the lack of quality-of-life data compared with alternative treatment strategies. Early clinical experiences with modest follow-up evaluating a variety of modalities are encouraging but hampered by study design limitations and small sample sizes.

CONCLUSIONS

Prostate focal therapy is a promising and emerging treatment strategy for men with a low risk of cancer progression or metastasis. Evaluation in formal prospective clinical trials is essential before this new strategy is accepted in clinical practice. Adequate trials must include appropriate end points, whether absence of cancer on biopsy or reduction in progression of cancer, along with assessments of safety and longitudinal alterations in quality of life.

Risk stratification of men choosing surveillance for low risk prostate cancer

PURPOSE

We sought to predict biopsy progression in men on prostate cancer surveillance.

MATERIALS AND METHODS

A total of 376 men with a median age of 65.5 years (range 45.8 to 79.5) with low risk prostate cancer on surveillance underwent at least 1 followup biopsy after diagnosis. Progression was defined at surveillance biopsy as Gleason pattern 4 or 5, greater than 2 biopsy cores with cancer or greater than 50% involvement of any core with cancer. Proportional hazards analysis was used to evaluate the association between covariates and progression at surveillance biopsy. The Kaplan-Meier method was used to estimate the probability of disease progression.

RESULTS

Of the 376 men 123 (32.7%) had progression a median of 5.6 years (range 0.3 to 8.5) after diagnosis. Percent free PSA and maximum percent core involvement at diagnosis were associated with progression, allowing stratification of the progression risk at initial surveillance biopsy. Cancer presence and PSA density at initial surveillance biopsy were associated with subsequent progression, allowing stratification of the cumulative incidence of progression 3 years after initial surveillance biopsy (cumulative incidence 11.1%, 95% CI 4.7 to 25.2 for negative biopsy and PSAD less than 0.08 ng/ml/cm(3) vs 53.6%, 95% CI 38.6 to 70.0 for positive biopsy and PSAD 0.08 ng/ml/cm(3) or greater, log rank test p <0.0001).

CONCLUSIONS

Clinical variables at diagnosis and at first surveillance biopsy during followup in an active surveillance program can be used to inform men about the likelihood of an unfavorable prostate biopsy. This information could improve patient and physician acceptance of active surveillance in carefully selected men.

Prostate cancer diagnosis

Prostate cancer is the fourth most common malignancy diagnosed in Missouri. The diagnosis may be clinically suspected based on an elevated serum prostate specific antigen (PSA) and/or digital rectal examination abnormality. Clinical symptoms are usually a manifestation of more advanced disease. The diagnosis is typically established by histopathologic examination of needle biopsy tissue. This article reviews clinical and pathological approaches to prostate cancer diagnosis, with a focus on clinically localized disease and needle biopsy diagnosis.

Treatment outcomes of radical prostatectomy in potential candidates for 3 published active surveillance protocols

OBJECTIVES

To examine the treatment outcomes of men who would have been eligible for active surveillance (AS) but underwent immediate radical retropubic prostatectomy (RRP). AS protocols are designed to spare the potential morbidity of treatment to patients with low-risk prostate cancer (PCa).

METHODS

From a prospective RRP database, we evaluated the tumor features and treatment outcomes for men who would have met 1 of 3 published AS criteria: (1) clinically localized disease, Gleason < or = 7, and no significant comorbidities (Patel et al, J Urol. 2004;171:1520-1524) (2) T1b-T2b N0M0 disease, Gleason < or = 7, and prostate-specific antigen < or = 15 ng/mL (Choo R et al. J Urol. 2002;167:1664-1669), or (3) T1c PCa (Mohler JL et al. World J Urol. 1997;15:364-368.).

RESULTS

3959, 3536, and 2330 RRP patients, respectively, would have met these AS criteria. At surgery, 3%-4% had a Gleason score of 8-10, 16%-19% had positive surgical margins, 15%-18% had extracapsular tumor extension, 3%-5% had seminal vesicle invasion, and 0.4%-1% had lymph node metastasis. The 5-year progression-free survival rate ranged from 84%-89%. Metastasis occurred in 0.1%-1.2%, and 0.1%-0.9% died of PCa. On multivariate analysis, Gleason score > 6 was the strongest predictor of biochemical progression.

CONCLUSIONS

A substantial proportion of men who might have been considered potential AS candidates had aggressive tumor features at RRP and/or progression. Biopsy Gleason score > 6 was the strongest predictor of adverse outcomes, highlighting the importance of limiting AS to patients with Gleason < or = 6. Overall, the accurate identification of patients with truly indolent PCa at the time of diagnosis remains challenging.

Pro-prostate-specific antigen measurements in serum and tissue are associated with treatment necessity among men enrolled in expectant management for prostate cancer

PURPOSE

We assessed the association of quantitative clinical and pathologic information, including serum and tissue pro-prostate-specific antigen (proPSA) measurements, with outcomes among men with prostate cancer in an expectant management (active surveillance) program.

EXPERIMENTAL DESIGN

We identified 71 men enrolled in expectant management with frozen serum and tissue available from diagnosis: 39 subsequently developed unfavorable biopsies (Gleason score > or =7, > or =3 cores positive for cancer, >50% of any core involved with cancer), whereas 32 maintained favorable biopsies (median follow-up, 3.93 years). Serum total PSA, free PSA (fPSA), and [-2]proPSA were measured by the Beckman Coulter immunoassay. [-5/-7]proPSA was evaluated in cancer and benign-adjacent areas (BAA) by quantitative immunohistochemistry. Cox proportional hazards and Kaplan-Meier analyses were used to identify significant associations with unfavorable biopsy conversion.

RESULTS

The ratio [-2]proPSA/% fPSA in serum was significantly higher at diagnosis (0.87 +/- 0.44 versus 0.65 +/- 0.36 pg/mL; P = 0.02) in men developing unfavorable biopsies. [-5/-7]proPSA tissue staining was more intense (4104.09 +/- 3033.50 versus 2418.06 +/- 1606.04; P = 0.03) and comprised a greater fractional area (11.58 +/- 7.08% versus 6.88 +/- 5.20%; P = 0.01) in BAA of these men. Serum [-2]proPSA/% fPSA [hazard ratio, 2.53 (1.18-5.41); P = 0.02], BAA [-5/-7]proPSA % area [hazard ratio, 1.06 (1.01-1.12); P = 0.02] and BAA [-5/-7]proPSA stain intensity [hazard ratio, 1.000213 (1.000071-1.000354); P = 0.003] were significantly associated with unfavorable biopsy in Kaplan-Meier and Cox analyses. Serum [-2]proPSA/% fPSA significantly correlated with BAA [-5/-7]proPSA % area (rho = 0.40; P = 0.002) and BAA [-5/-7]proPSA stain intensity (rho = 0.33; P = 0.016).

CONCLUSIONS

In a prospective cohort of men enrolled into expectant management for prostate cancer, serum and tissue levels of proPSA at diagnosis are associated with need for subsequent treatment. The increase in serum proPSA/% fPSA might be driven by increased proPSA production from "premalignant" cells in the prostate BAA.

Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer

PURPOSE We assessed the outcome of a watchful-waiting protocol with selective delayed intervention by using clinical prostate-specific antigen (PSA), or histologic progression as treatment indications for clinically localized prostate cancer. PATIENTS AND METHODS 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 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. Results A total of 450 patients have been observed with active surveillance. Median follow-up was 6.8 years (range, 1 to 13 years). Overall survival was 78.6%. The 10-year prostate cancer actuarial survival was 97.2%. Overall, 30% of patients have been reclassified as higher risk and have been offered definitive therapy. Of 117 patients treated radically, the PSA failure rate was 50%, which was 13% of the total cohort. PSA doubling time of 3 years or less was associated with an 8.5-times higher risk of biochemical failure after definitive treatment compared with a doubling time of more than 3 years (P < .0001). The hazard ratio for nonprostate cancer to prostate cancer mortality was 18.6 at 10 years. CONCLUSION We observed a low rate of prostate cancer mortality. Among the patients who were reclassified as higher risk and who were treated, PSA failure was relatively common. Other-cause mortality accounted for almost all of the deaths. Additional studies are warranted to improve the identification of patients who harbor more aggressive disease despite favorable clinical parameters at diagnosis.

Testing the most stringent criteria for selection of candidates for active surveillance in patients with low-risk prostate cancer

OBJECTIVE

To test the ability of two of the most stringent criteria used to identify patients with low-risk prostate cancer suitable for active surveillance (AS) to correctly exclude patients with unfavourable prostate cancer characteristics.

PATIENTS AND METHODS

The study included 874 consecutive patients treated with radical prostatectomy (RP). We selected patients who could have been selected for AS according to the van den Bergh et al. and the Carter et al. criteria. We analysed the rates of advanced disease in these patients, defined as presence of either extracapsular extension (ECE), seminal vesicle invasion (SVI), lymph node invasion (LNI) and Gleason sum of 8-10 or 7-10.

RESULTS

Of 874 patients, 85 (9.7%) and 61 (6.9%) patients, respectively, qualified for AS according to the tested criteria. Within the van den Bergh et al. candidates, 5.9, 1.2, 1.2 and 1.2% of patients, respectively, showed ECE, SVI, LNI and high-grade Gleason sum 8-10 at pathology. Within the Carter et al. candidates, 3.3, 0, 3.3 and 0% of patients, respectively, showed ECE, SVI, LNI and high-grade Gleason sum 8-10. The cumulative rate of unfavourable characteristics was 7.1 and 3.3%. The rate increased to 28.2 and 27.9%, respectively, when Gleason sum 7 was considered as an unfavourable prostate cancer.

CONCLUSIONS

The use of the strictest criteria for AS inclusion identified 7-10% of the men in our cohort of men undergoing RP, as men that would have been eligible for AS. Among this small proportion, between 3.3 and 7.1% of patients harboured unfavourable prostate cancer characteristics. The clinical implications of these misclassification rates remain to be determined.

Radical prostatectomy findings in patients predicted to have low-volume/low-grade prostate cancer diagnosed by extended-core biopsies: an analysis of volume and zonal distribution of tumour foci

OBJECTIVE

To measure total tumour volume (TTV) and dominant TV (DTV) in radical prostatectomy (RP) specimens from patients predicted to have low-volume, low-grade (LV/LG) prostate cancer, as this entity can be predicted from biopsy findings and prostate-specific antigen (PSA) level, but tumour under-sampling remains a challenge in active surveillance programmes.

PATIENTS AND METHODS

This was a retrospective study from an academic centre, of men with prostate cancer treated from 2000 to 2007, with a PSA level of <10 ng/mL and one core of cancer from an extended scheme showing either Gleason score (GS) 3 + 3 of <3.0 mm or 3 + 4 of <2.0 mm. All men had RP, and the TTV, DTV, tumour location, pathological GS and stage were measured.

RESULTS

Of 3055 RPs, 66 (2.1%) met the inclusion criteria. The core with cancer was from a sextant and alternative site in 26 (39%) and 40 (61%) patients, respectively. A pathological GS 3 + 3 or 3 + 4 was assigned to 94%, while 6% were GS > or = 4 + 3; all 66 tumours were organ-confined. The median (range) TTV and DTV were 0.15 (0.0008-5.06) and 0.14 (0.0008-5.04) mL, respectively. The median number of tumour foci was 3 (1-7), being unifocal in 17/66 (26%) and multifocal in 49/66 (74%). The transition zone was involved in 29% of unifocal and 71% of multifocal tumours. Of all 66 patients, the TTV was <0.5 mL in 47 (71%), and of 59 patients with biopsy GS 3 + 3, 33 (56%) had a TTV of <0.5 mL and pathological GS 3 + 3. Of 19 patients with a TTV of > or =0.5 mL, the median TTV was 1.06 (0.51-5.05) mL, with tumour foci of transition zone origin in 16 (84%). The study was limited by its retrospective design and small sample size.

CONCLUSIONS

Using conservative selection criteria for predicting LV/LG cancer, RP specimens showed organ-confined disease in all cases, upgrading to GS > or = 4 + 3 in 6%, and TTV <0.5 mL in 71% of cases. The transition zone is a common location of under-sampled disease.