Preliminary results of the Spanish Association of Urology National Registry in Active Surveillance for prostate cancer

Update and optimization of active surveillance in prostate cancer in 2021

INTRODUCTION AND OBJECTIVES

Within the paradigm shift of the last decade in the management of prostate cancer (PCa), perhaps the most relevant event has been the emergence of active surveillance (AS) as a mandatory strategy in low-risk disease. We carry out a critical review of the clinical, pathological and radiological improvements that allow optimizing AS in 2021.

MATERIAL AND METHODS

Critical narrative review of the literature on improvement issues and controversial aspects of AS.

RESULTS

Adequate use of traditional criteria, optimized by enhanced biopsy and calculation of the prostate volume technique thanks to multiparametric magnetic resonance imaging (mpMRI) allow a better selection of patients for AS. This management should not be limited to patients under 60years of age, and patients with intermediate-risk PCa should be carefully selected to be included. Biopsies are still required in the follow-up, which can be personalized according to risk patterns. The pathologist must identify the cribriform or intraductal histology on biopsies in order to exclude these patients from AS, in the same way as with patients with alterations in DNA repair genes.

CONCLUSIONS

Controversial indications such as the inclusion of patients from intermediate-risk groups, or the transition to active treatment due to exclusive progression in tumor volume, should be further optimized. It is possible that the future competition of tissue biomarkers, the refinement of objective parameters of mpMRI and the validation of PSA kinetics calculators may sub-stratify risk groups.

The impact of time from biopsy to radical prostatectomy on Gleason score undergrading and other related factors

INTRODUCTION

Gleason score biopsy undergrading (GSBU) can have an impact on the management and prognosis of patients with prostate cancer. We analyze the possible impact of time and other clinical and analytical factors in the appearance of GSBU in our series.

PATIENTS AND METHOD

Ambispective, multicenter study of 1955 patients with localized prostate cancer undergoing radical prostatectomy between 2005 and 2018. Descriptive statistics and hypothesis testing are reported by univariate and multivariate analyses.

RESULTS

Mean age 63.69 (44-80) years, median PSA 8.70 ng / ml (1.23-99). GSBU was observed in 34.7% of the entire cohort. In 72.8% of the cases, the GSBU occurred in one consecutive Gleason score, with the progression from 3 + 3 to 3 + 4 being the most frequent (289 patients, 47.6%). Performing radical prostatectomy 90-180 days before or after the biopsy does not have an impact on its undergrading in any of the groups. In the univariate and multivariate analysis, the presence of tumor or pathological rectal examination in both lobes, the tumor load ≥50% of cylinders and a DPSA ≥0.20, showed independent discriminative capacity to select patients who presented GSBU.

CONCLUSIONS

The time from biopsy to radical prostatectomy did not show impact on GSBU. The number of affected cylinders, bilateral tumor and DPSA are easily accessible parameters that can help us select patients with greater probability of presenting GSBU.

Long-term oncological results of treatment for high-risk prostate cancer using radical prostatectomy in a cancer hospital

OBJECTIVES

To analyse the most relevant oncologic results of treatment using radical prostatectomy (RP) for high-risk prostate cancer (HRPC) in a specialist cancer hospital.

MATERIAL AND METHODS

A descriptive retrospective study of RP was conducted at our centre from 1986 to 2017 on HRPC whose primary objective was to determine overall survival (OS) and cancer-specific survival (CSS). The study's secondary objectives were to determine biochemical progression-free survival (BPFS), metastasis-free survival (MFS), rescue therapy-free survival (RTFS), hormone therapy-free survival (HTFS) and the development of castration-resistant prostate cancer. We performed a Cox regression analysis to establish predictive models and to better understand the weight of each variable that defines high risk.

RESULTS

A total of 2093 RPs were performed, 480 (22.9%) of which were for HRPC. The median follow-up for the overall series was 79.57 months (P_25-75 37.92-135.16). Lymphadenectomy was not performed in 6.5% of the cases. The lymphadenectomy was of the obturator type in 51.2% of the cases and extended in 42.3%. Overall survival at 5, 10 and 15 years was 89.8% (95% CI 86.7-92.9%), 73.3% (95% CI 68-78.6%) and 51.4% (95% CI 43.8-59%), respectively. CSS at 5, 10 and 15 years was 94.8% (95% CI 92.4-97.2%), 84.0% (95% CI 79.3-88.7%) and 75.5% (95% CI 68.8-82.2%), respectively. MFS at 5, 10 and 15 years was 87.4% (95% CI 84.1-90.7%), 72.2% (95% CI 66.7-77.7%) and 61.7% (95% CI 54.3-69.1%), respectively. A total of 120 patients of 477 analysed (25.1%) required rescue radiation therapy, and 293/477 never required hormone therapy (61.4%). Of the 93 pN1 patients, 33 (35.5%) did not require hormone therapy. The time from RP to biochemical progression was the variable with the greatest prognostic weight for MFS, CSS and overall survival.

CONCLUSIONS

RP plus extended lymphadenectomy should be the first therapeutic manoeuvre when feasible within a multimodal strategy. A longer follow-up of the series is needed to validate the hypothesis of better oncologic results based on the earlier implementation of rescue radiation therapy, extended lymphadenectomy and drugs that prolong survival in the CRPC phase.

Variability in the multicentre National Registry in Active Surveillance; a questionnaire for urologists

BACKGROUND

Our main objective was to report the current use of active surveillance in Spain and to identify areas for potential improvement.

METHODS

A questionnaire generated by the Platform for Multicentre Studies of the Spanish Urology Association (AEU/PIEM/2014/0001, NCT02865330) was sent to all associate researchers from January to March 2016. The questionnaire included 7 domains covering various aspects of active surveillance.

RESULTS

Thirty-three of the 41 associate researchers responded to the questionnaire. Active surveillance is mainly controlled by the urology departments (87.9%). There was considerable heterogeneity in the classical clinical-pathological variables as selection criteria. Only 36.4% of the associate researchers used prostate-specific antigen density (PSAd). Multiparametric magnetic resonance imaging (mpMRI) was clearly underused as initial staging (6%). Only 27.3% of the researchers stated that their radiology colleagues had a high level of experience in mpMRI. In terms of the confirmation biopsy, most of the centres used the transrectal pathway, and only 2 out of 33 used the transperineal pathway or fusion software. Half of the researchers interviewed applied active treatment when faced with disease progression to Gleason 7 (3+4). There was no consensus on when to transition to an observation strategy.

CONCLUSIONS

The study showed the underutilisation of informed consent and quality-of-life questionnaires. PSAd was not included as a decisive element in the initial strategy for most researchers. There was a lack of confidence in the urologists' mpMRI experience and an underutilisation of the transperineal pathway. There was also no consensus on the follow-up protocols and active treatment criteria, confirming the need for prospective studies to analyse the role of mpMRI and biomarkers.

Role of the 4Kscore test as a predictor of reclassification in prostate cancer active surveillance

BACKGROUND

Management of active surveillance (AS) in low-risk prostate cancer (PCa) patients could be improved with new biomarkers, such as the 4Kscore test. We analyze its ability to predict tumor reclassification by upgrading at the confirmatory biopsy at 6 months.

METHODS

Observational, prospective, blinded, and non-randomized study, within the Spanish National Registry on AS (AEU/PIEM/2014/0001; NCT02865330) with 181 patients included after initial Bx and inclusion criteria: PSA ≤10 ng/mL, cT1c-T2a, Grade group 1, ≤2 cores, and ≤5 mm/50% length core involved. Central pathological review of initial and confirmatory Bx was performed on all biopsy specimens. Plasma was collected 6 months after initial Bx and just before confirmatory Bx to determine 4Kscore result. In order to predict reclassification defined as Grade group ≥2, we analyzed 4Kscore, percent free to total (%f/t) PSA ratio, prostate volume, PSA density, family history, body mass index, initial Bx, total cores, initial Bx positive cores, initial Bx % of positive cores, initial Bx maximum cancer core length and initial Bx cancer % involvement. Wilcoxon rank-sum test, non-parametric trend test or Fisher's exact test, as appropriate established differences between groups of reclassification.

RESULTS

A total of 137 patients met inclusion criteria. Eighteen patients (13.1%) were reclassified at confirmatory Bx. The %f/t PSA ratio and 4Kscore showed differences between the groups of reclassification (Yes/No). Using 7.5% as cutoff for the 4Kscore, we found a sensitivity of 89% and a specificity of 29%, with no reclassifications to Grade group 3 for patients with 4Kscore below 7.5% and 2 (6%) missed Grade group 2 reclassified patients. Using this threshold value there is a biopsy reduction of 27%. Additionally, 4Kscore was also associated with changes in tumor volume.

CONCLUSIONS

Our preliminary findings suggest that the 4Kscore may be a useful tool in the decision-making process to perform a confirmatory Bx in active surveillance management.

Cryotherapy versus high-intensity focused ultrasound for treating prostate cancer: Oncological and functional results

CONTEXT AND OBJECTIVE

The increasingly early diagnosis of prostate cancer requires a search for therapeutic alternatives with good oncological results that in turn facilitate a good long-term quality of life. This review analyses 2 minimally invasive therapies for treating localised prostate cancer in terms of oncological and functional results, as well as the complications resulting from the therapies.

ACQUISITION OF EVIDENCE

A systematic literature review was conducted of the treatment of localised prostate cancer with 2 ablative techniques as the primary therapy: cryosurgery or cryotherapy and high intensity focused ultrasound (HIFU). We included patients who underwent procedures that included the entire gland, with hemiablation or focal therapy, which were indicated for low to intermediate-risk prostate cancer according to the D'Amico criteria. We excluded patients with high-risk prostate cancer and those who underwent any prior treatment for prostate cancer.

SYNTHESIS OF THE EVIDENCE

After conducting the literature search and excluding the studies that did not meet the protocol criteria, we reviewed a total of 14 studies, with a total of 350 patients treated using cryotherapy and 1107 treated with HIFU. All studies were either prospective or retrospective and were not randomised. The patients' mean age was younger than 75 years. Overall, the rate of disease recurrence in the patients treated with cryotherapy varied between 13.2% and 26%, while the rate for those treated with HIFU varied between 7.3% and 67.9%. The overall demonstrated continence at 12 months was 97.6-100% for cryotherapy and 96-100% for HIFU. In terms of sexual potency rates, cryotherapy showed complete potency at 12 months for 86-100% of the patients treated with focal cryotherapy and slightly lower rates for hemiablation (76.9-100%) and total therapy (39%). HIFU showed potency rates of 89%, 52-80% and 33-78% for focal therapy, hemiablation and total therapy, respectively.

CONCLUSIONS

Both techniques have comparable functional results, although the somewhat poorer oncological results for HIFU reflect a steeper learning curve, which could lead to its use in centres with high volumes of patients.

Our experience in the management of prostate cancer in renal transplant recipients

INTRODUCTION AND OBJECTIVES

The management of Prostate cancer (PCa) in renal transplant recipients (RTR) is challenging and remain controversial. Currently there is no consensus about this condition. The aim of the study was to analyse our experience in the diagnosis and management of PCa in RTR.

METHOD

Retrospective monocentric study of a prospective and consecutive database from 2003-2017. Inclusion of RTR diagnosed of PCa. Staging and treatment in agreement with the contemporary guidelines. The main outcome measures included clinical staging, type of treatment, oncological outcomes and follow-up.

RESULTS

1,330 renal transplants were performed (787 males), diagnosed of PCa in 33 RTR (4.2%), mean age 66years±6.3 (51-78). Median PSA was 8.8ng/ml and PSA ratio 0.19. Mean time between renal transplantation and PCa diagnosis 130months±90 (2-236).

TREATMENTS

Radical prostatectomy (RP) (n=22; 66.7%), Radiation therapy (RT) with Androgen deprivation therapy (ADT) (n=7; 21.2%), Active surveillance (n=3; 9.1%), ADT (n=1; 3%). No graft loss neither impaired renal function due to PCa treatment was reported. After RP two patients (9.1%) presented biochemical recurrence treated with RT. Remission of the 100%. Mean follow-up was 61months±37 (6-132).

CONCLUSIONS

PCa in renal transplant patients can be managed with the same therapeutic options as in the general population. Active surveillance should also be provided in RTR despite being under immunosuppressive therapy.

3+4 = 6? Implications of the stratification of localised Gleason 7 prostate cancer by number and percentage of positive biopsy cores in selecting patients for active surveillance

OBJECTIVE

To determine whether the number and percentage of positive biopsy cores identify a Gleason 3+4 prostate cancer (PC) subgroup of similar biologic behaviour to Gleason 3+3.

MATERIAL AND METHOD

An observational post-radical prostatectomy study was conducted of a cohort of 799 patients with localised low-risk (n=582, Gleason 6, PSA <10ng/ml and cT1c-2a) and favourable intermediate PC (n=217, Gleason 3+4, PSA ≤10 ng/ml and pT2abc). The Gleason 3+4 tumours were stratified by number (≤3 vs.>3) and by percentage of positive cores (≤33% vs. >33%). We analysed the tumours' association with the biochemical recurrence risk (BRR) and cancer-specific mortality (CSM). We conducted various predictive models using Cox regression and estimated (C-index) and compared their predictive capacity.

RESULTS

With a median follow-up of 71 months, the BRR and CSM of the patient group with Gleason 3+4 tumours and a low number (≤3) and percentage (≤33%) of positive cores were not significantly different from those of the patients with Gleason 6 tumours. At 5 and 10 years, there were no significant differences in the number of biochemical recurrences, the probability of remaining free of biochemical recurrences, the number of deaths by PC or the probability of death by PC between the 2 groups. In contrast, the patients with Gleason 3+4 tumours and more than 33% of positive cores presented more deaths by PC than the patients with Gleason 6 tumours. At 10 years, the probability of CSM was significantly greater. This subgroup of tumours showed a significantly greater BRR (RR, 1.6; P=.02) and CSM (RR, 5.8, P≤.01) compared with the Gleason 6 tumours. The model with Gleason 3+4 stratified by the percentage of positive cores significantly improved the predictive capacity of BRR and CSM.

CONCLUSIONS

Fewer than 3 cores and a percentage <33% of positive cores identifies a subgroup of Gleason 3+4 tumours with biological behaviour similar to Gleason 6 tumours. At 10 years, there were no differences in BRR and CSM between the 2 groups. These results provide evidence supporting active surveillance as an alternative for Gleason 3+4 tumours and low tumour extension in biopsy.

The management of active surveillance in prostate cancer: validation of the Canary Prostate Active Surveillance Study risk calculator with the Spanish Urological Association Registry

The follow up of patients on active surveillance requires to repeat prostate biopsies. Predictive models that identify patients at low risk of progression or reclassification are essential to reduce the number of unnecessary biopsies. The aim of this study is to validate the Prostate Active Surveillance Study risk calculator (PASS-RC) in the multicentric Spanish Urological Association Registry of patients on active surveillance (AS), from common clinical practice.

Competing risk analysis of mortality in prostate cancer treated with radical prostatectomy

OBJECTIVE

To determine the risk of cancer-specific mortality (CSM) versus the competing risk of mortality by other causes (MOC) in patients with localised prostate cancer (LPC) treated with radical prostatectomy (RP).

MATERIAL AND METHOD

An observational cohort study of 982 patients with LPC treated with RP selected from our department's PC registry database. A competing risk analysis was performed, calculating the probability of CSM in the presence of the competing risk of MOC. Cumulative incidence curves were constructed, and point estimates were performed at 5, 10 and 15 years. The analysis was stratified by age (≤65 vs. >65 years) and risk group: low (Gleason score ≤6 and pT2abc); intermediate (Gleason score of 7 and pT2abc) and high (Gleason score of 8-10 or pT3ab).

RESULTS

With a median follow-up of 60 months, the overall probability of dying from PC was 3.5%, and the probability of dying from other causes was 9%. A competing effect for MOC was observed. The risk of MOC was almost 3 times greater than that of CSM. This effect remained for all risk groups, although its magnitude decreased progressively according to the risk group level. At 10 years, CSM was only 0%, 1% and 2% for the low, intermediate and high-risk groups, respectively, while the likelihood of MOC was 4%, 4% and 10%, respectively. The mortality risk was shown after 10years of follow-up and was higher for other causes not attributable to PC and for patients older than 65years.

CONCLUSIONS

The benefit of RP might be overestimated, given that the risk of MOC is greater than that of CSM, regardless of the age group and risk group, especially after 10years of follow-up. The only parameter that varied was the magnitude of the CSM/MOC ratio. This information could help in choosing the active treatment for patients with LPC and short life expectancies.