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Long-term use of 5-alpha-reductase inhibitors is safe and effective in men on active surveillance for prostate cancer. Prostate Cancer Prostatic Dis 2020; 24:69-76. [PMID: 32152437 DOI: 10.1038/s41391-020-0218-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although 5-alpha-reductase inhibitors (5ARIs) have been shown to benefit men with prostate cancer (PCa) on active surveillance (AS), their long-term safety remains controversial. Our objective is to describe the long-term association of 5ARI use with PCa progression in men on AS. MATERIALS/SUBJECTS AND METHODS The cohort of men with low-risk PCa was derived from a prospectively maintained AS database at the Princess Margaret (1995-2016). Pathologic, grade, and volume progression were the primary end points. Kaplan-Meier time-to-event analysis was performed and Cox proportional hazards regression was used to determine predictors of progression where 5ARI exposure was analyzed as a time-dependent variable. Patients who came off AS prior to any progression events were censored at that time. RESULTS The cohort included 288 men with median follow-up of 82 months (interquartile range: 37-120 months). Among non-5ARI users (n = 203); 114 men (56.2%) experienced pathologic progression compared with 24 men (28.2%) in the 5ARI group (n = 85), (p < 0.001). Grade and volume progression were higher in the non-5ARI group compared with the 5ARI group (n = 82; 40.4% vs. n = 19; 22.4% respectively, p = 0.003 for grade progression; n = 87; 43.1% and n = 15; 17.7%, respectively for volume progression p < 0.001). Lack of 5ARI use was independently positively associated with pathologic progression (HR: 2.65; CI: 1.65-4.24), grade progression (HR: 2.75; CI: 1.49-5.06), and volume progression (HR: 3.15; CI: 1.78-5.56). The frequency of progression to high-grade (Grade Group 4-5) tumors was not significantly different between the groups. CONCLUSIONS Use of 5ARIs diminished both grade and volume progression without an increased risk of developing Grade Groups 4-5 disease.
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Initial diagnosis of insignificant cancer, high-grade prostatic intraepithelial neoplasia, atypical small acinar proliferation, and negative have the same rate of upgrade to a Gleason score of 7 or higher on repeat prostate biopsy. Hum Pathol 2018; 79:116-121. [DOI: 10.1016/j.humpath.2018.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/05/2018] [Accepted: 05/20/2018] [Indexed: 11/19/2022]
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Komisarenko M, Martin LJ, Finelli A. Active surveillance review: contemporary selection criteria, follow-up, compliance and outcomes. Transl Androl Urol 2018; 7:243-255. [PMID: 29732283 PMCID: PMC5911534 DOI: 10.21037/tau.2018.03.02] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The primary goal of active surveillance (AS) is to prevent overtreatment by selecting patients with low-risk prostate cancer (PCa) and closely monitoring them so that definitive treatment can be offered when needed. With the increasing popularity of AS as a management strategy for men with localized PCa, it is important to understand all the contemporary guidelines and criteria that exist for AS and the differences among them. No single optimal management strategy for clinically localized, early-stage disease has been universally accepted. The implementation of AS varies widely between institutions, from inclusion criteria to follow-up protocols, with the most notable differences seen in maximum accepted Gleason score, T-stage and prostate-specific antigen (PSA) parameters. The objectives of this review were to systematically summarize the current literature on AS strategy, present an overview of the various published guidelines and criteria that are used for AS at several major institutions as well as discuss goals and trade-offs of the various criteria. A comprehensive search of the PubMed and Embase databases from 1990 to 2017 was performed to identify studies pertaining to AS criteria and trends. Trends in AS uptake and use in Canada, USA and Europe were reviewed to demonstrate the current trends and outcomes of AS to offer greater insight into the differences, nature and efficacy of various AS protocols. AS is a compelling antidote to the current PCa overtreatment phenomena; however, when considering patients for AS it is important to understand the differences between protocols, and review published results to appreciate the impact on follow-up.
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Affiliation(s)
- Maria Komisarenko
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lisa J Martin
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Antonio Finelli
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Wang H, Gu L, Wu Y, Feng D, Duan J, Wang X, Huang Y, Wu S, Chen J, Luo G, Zhang X. The values of neutrophil-lymphocyte ratio and/or prostate-specific antigen in discriminating real Gleason score ≥ 7 prostate cancer from group of biopsy-based Gleason score ≤ 6. BMC Cancer 2017; 17:629. [PMID: 28874127 PMCID: PMC5586011 DOI: 10.1186/s12885-017-3614-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 08/28/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The discrepant concordance between biopsy and radical prostatectomy (RP) specimen are well reported. To validate the clinical usefulness of neutrophil-lymphocyte ratio (NLR) in discriminating real GS ≥ 7 PCa from biopsy-based GS ≤ 6 PCa in comparison with serum total prostate-specific antigen (tPSA) and value of their combination. METHODS One hundred one patients who underwent physical examinations incidentally found elevated tPSA and subsequently received biopsy with a conclusion of GS ≤ 6 and RP with an interval of 4-6 weeks after biopsy were enrolled. NLR and tPSA were obtained within 15 days prior to biopsy. Logistic regression model was applied appropriately; McNemar tests and AUC model were performed to evaluate differences among tPSA, NLR and their combination and corresponding diagnostic power respectively. RESULTS The pathological results from RP specimen comprised 61 patients with GS ≤ 6 and 100 patients with GS ≥ 7. Higher tPSA and NLR were significantly associated with patients with actual GS ≥ 7 (All P < 0.05) concurrently. Multivariate logistic regression indicated that tPSA (OR = 1.088, 95% C.I. = 1.029-1.151, P = 0.003) and NLR (OR = 1.807, 95% C.I. = 1.021-3.200, P = 0.042) could be independent predictors for GS groupings. Under cutoff value of 14.09 ng/ml for tPSA and 2.25 for NLR, the sensitivity, specificity and accuracy were 60.0%, 80.3% and 67.7% for tPSA, 42%, 88.5% and 59.6% for NLR, and 71.0%, 75.4% and 72.7% for combination of tPSA and NLR (tPSA + NLR) respectively. The sensitivity of tPSA + NLR was significantly higher in comparison with tPSA (P = 0.001) and NLR (P < 0.001). Except for sensitivity, no significant difference was found between tPSA and NLR in specificity (P = 0.227) and accuracy (P = 0.132). tPSA got the largest AUC with 0.732 (p < 0.001, 95% C.I.: 0.651-0.813). CONCLUSIONS Serum tPSA and NLR were significantly elevated among GS ≥ 7 PCa concurrently. The combination of tPSA and NLR might have additional benefit to biopsy on discriminating real GS ≥ 7 Pca from biopsy-based GS ≤ 6 PCa. More stratification models and prospectively multicenter studies are necessary.
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Affiliation(s)
- Hanfeng Wang
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, People's Republic of China
| | - Liangyou Gu
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, People's Republic of China
| | - Yongjie Wu
- Department of General Surgery, Chinese PLA 264 Hospital, Taiyuan, 030000, China
| | - Dan Feng
- Hospital Management Institute, Medical Statistic Division, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, China
| | - Junyao Duan
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, People's Republic of China
| | - Xiaocong Wang
- Department of Pathology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, China
| | - Yong Huang
- Department of Pathology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, China
| | - Shengpan Wu
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, People's Republic of China
| | - Jianwen Chen
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, People's Republic of China
| | - Guangda Luo
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, People's Republic of China
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, 100853, People's Republic of China.
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Bhindi B, Jiang H, Poyet C, Hermanns T, Hamilton RJ, Li K, Toi A, Finelli A, Zlotta AR, van der Kwast TH, Evans A, Fleshner NE, Kulkarni GS. Creation and internal validation of a biopsy avoidance prediction tool to aid in the choice of diagnostic approach in patients with prostate cancer suspicion. Urol Oncol 2017; 35:604.e17-604.e24. [PMID: 28781111 DOI: 10.1016/j.urolonc.2017.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/03/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION To reduce unnecessary prostate biopsies while using novel tests judiciously, we created a tool to predict the probability of clinically significant prostate cancer (CSPC) vs. low-risk prostate cancer or negative biopsy (i.e., when intervention is likely not needed) among men undergoing initial or repeat biopsy. METHODS Separate models were created for men undergoing initial and repeat biopsy, identified from our institutional biopsy database and the placebo arm of the REDUCE trial, respectively, to predict the presence of CSPC (Gleason≥7 or>33% of cores involved). Predictors considered included age, race, body mass index, family history of prostate cancer, digital rectal examination, prostate volume, prostate-specific antigen (PSA), free-to-total PSA, presence of high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation on prior biopsy, number of prior biopsies, and number of cores previously taken. Multivariable logistic regression models that minimized the Akaike Information Criterion and maximized out-of-sample area under the receiver operating characteristics curve (AUC) were selected. RESULTS Of 7,963 biopsies (initial = 2,042; repeat = 5,921), 1,138 had CSPC (initial = 870 [42.6%]; repeat = 268 [4.5%]). Age, race, body mass index, family history, digital rectal examination, and PSA were included in the initial biopsy model (out-of-sample AUC = 0.74). Age, prostate volume, PSA, free-to-total PSA, prior high-grade prostatic intraepithelial neoplasia, and number of prior biopsies were included in the repeat biopsy model (out-of-sample AUC = 0.81). CONCLUSION These prediction models may help guide clinicians in avoiding unnecessary initial and repeat biopsies in men unlikely to harbor CSPC. This tool may also allow for the more judicious use of novel tests only in patients in need of further risk stratification before deciding whether to biopsy.
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Affiliation(s)
- Bimal Bhindi
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; Department of Urology, Mayo Clinic, Rochester, MN.
| | - Haiyan Jiang
- Department of Biostatistics, University Health Network, University of Toronto, Toronto, Canada
| | - Cedric Poyet
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas Hermanns
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Robert J Hamilton
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - Kathy Li
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - Ants Toi
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Canada
| | - Antonio Finelli
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - Alexandre R Zlotta
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | | | - Andrew Evans
- Institute for Clinical and Evaluative Sciences, University of Toronto, Toronto, Canada
| | - Neil E Fleshner
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - Girish S Kulkarni
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; Department of Pathology, University Health Network, University of Toronto, Toronto, Canada
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Population-based study of grade progression in patients who harboured Gleason 3 + 3. World J Urol 2017; 35:1689-1699. [PMID: 28500489 DOI: 10.1007/s00345-017-2047-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE This study aimed to evaluate (1) the time interval between a decision to commence on active surveillance (AS) and grade progression in community practice; (2) factors predicting grade progression in localised prostate cancer (CaP) patients apparently undergoing AS. METHODS Data from the Prostate Cancer Outcomes Registry-Victoria were used to analyze men with Gleason 3 + 3 CaP or less who had at least one repeat biopsy. Unadjusted and adjusted 5-year Kaplan-Meier survival curves were used to assess the time to grade progression. Both univariate and multivariate analyses for grade progression were performed using Cox proportional hazards. RESULTS The cohort included 951 men. Overall, 39% of men had Gleason grade reclassified to a higher risk disease state with median of 2.2 years [IQR 1.2-3.7 years]. Men who harboured cT2 disease were 30% more likely to have upgrading compared to men with cT1 disease (adjusted HR: 1.3, 95% CI 1.0-1.6, p = 0.048). Half of the men with cT2 in our cohort had their Gleason grade reclassified within 1.6 years from diagnosis as compared with 2.7 years for the cT1 group. The presence of percentage of core involvement >25.0% and a PSA velocity of >1.01 ng/mL/year remained significant for a higher progression rate. The adjusted HR: 1.6; 95% CI [1.2-2.3], p = 0.004; adjusted HR: 1.6, 95% CI [1.2-2.4], p = 0.021, for percent of core involvement of 25.1-37.5%, and ≥37.6%, respectively. The adjusted HRs and p value associated with PSA velocity were 1.5; 95% CI [1.1-2.1], p = 0.016 and 1.6; 95% CI [1.2-2.3], p = 0.003 for PSA velocity values of 1.01-2 ng/mL per year and >2 ng/mL per year, respectively. Men who were diagnosed in regional hospital and subsequently had biopsy in metropolitan hospital were twice at risk of having Gleason upgrade compared to those whom both diagnostic and surveillance biopsies were carried out in metropolitan hospitals (adjusted HR: 1.9; 95% CI 1.1-3.3, p = 0.029). CONCLUSIONS When placing men on AS and considering time to histologic progression, clinicians should pay particular attention to the likely accuracy of the diagnostic specimen, their tumour stage, volume of tumour (percent of core involvement), and rising PSA. Those diagnosed with T2 disease and had >25.0% of core involvement, and a PSA velocity greater than 1 ng/mL per year is at particular risk for more rapid disease progression and, for this reason, should be counselled on the importance of following the recommended surveillance regimen. For half of these men, their disease will have 'progressed' according to biopsy results in 2 years.
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Taneja SS. Re: Quantified Clinical Risk Change as an End Point during Prostate Cancer Active Surveillance. J Urol 2017; 197:699-700. [DOI: 10.1016/j.juro.2016.12.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kovac E, Lieser G, Elshafei A, Jones JS, Klein EA, Stephenson AJ. Outcomes of Active Surveillance after Initial Surveillance Prostate Biopsy. J Urol 2016; 197:84-89. [PMID: 27449260 DOI: 10.1016/j.juro.2016.07.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE We analyzed the rates of disease reclassification at initial and subsequent surveillance prostate biopsy as well as the treatment outcomes of deferred therapy among men on active surveillance for prostate cancer. MATERIALS AND METHODS From a prospective database we identified 300 men on active surveillance who had undergone initial surveillance prostate biopsy, with or without confirmatory biopsy, within 1 year of diagnosis. Of these men 261 (87%) were classified as having NCCN very low or low risk disease at diagnosis. Disease reclassification on active surveillance was defined as the presence of 50% or more positive cores and/or surveillance prostate biopsy Gleason score upgrading. Patients with type I disease reclassification included those with any surveillance prostate biopsy Gleason score upgrading, while patients with type II reclassification had to have primary Gleason pattern 4-5 disease on surveillance prostate biopsy. Outcomes after initial surveillance prostate biopsy were evaluated using actuarial analyses. RESULTS At the time of initial surveillance prostate biopsy 49 (16%) and 19 (6%) patients had type I and type II disease reclassification, respectively. Those who underwent confirmatory biopsy had significantly reduced rates of type I (9% vs 23%, p=0.001) and type II (3% vs 9%, p=0.01) reclassification at initial surveillance prostate biopsy. For the 251 patients without disease reclassification at initial surveillance prostate biopsy the 2-year rates of subsequent type I and II reclassification were 17% (95% CI 0-24) and 3% (95% CI 0.1-7), respectively. For the 93 patients who received deferred therapy the 5-year biochemical progression-free probability was 89% (95% CI 79-98), including 95%, 82% and 70% among those without, and those with type I and type II disease reclassification, respectively. CONCLUSIONS Patients on active surveillance with stable disease at the time of initial surveillance prostate biopsy may be appropriate candidates for less intensive surveillance prostate biopsy schedules.
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Affiliation(s)
- Evan Kovac
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Gregory Lieser
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed Elshafei
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio; Urology Department, Medical School, Cairo University, Giza, Egypt
| | - J Stephen Jones
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric A Klein
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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Eslami M, Khamechian T, Mazoochi T, Ehteram H, Sehat M, Alizargar J. Evaluation of survivin expression in prostate specimens of patients with prostate adenocarcinoma and benign prostate hyperplasia underwent transurethral resection of the prostate or prostatectomy. SPRINGERPLUS 2016; 5:621. [PMID: 27330887 PMCID: PMC4870532 DOI: 10.1186/s40064-016-2283-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 05/05/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Survivin is a newly found member of the inhibitors of apoptosis proteins, which plays a certain role in cancer. Survivin has a distinctly different expression in cancers, including prostate cancer. We are searching for the relationship between survivin levels in normal prostate tissue, benign prostate hyperplasia (BPH), and prostate adenocarcinoma in this study. RESULTS The study surveyed 282 prostate samples, 94 normal, 94 BPH, and 94 prostate adenocarcinoma samples. Survivin expression was absent in normal prostate tissues. In the BPH group, the survivin expression level was higher than that of the normal group. In the adenocarcinoma group, the survivin expression level was higher than that of the BPH group. There was a significant association between survivin expression level and the adenocarcinoma stage. CONCLUSION Although there is no expression of survivin in normal prostate tissue, its expression is slightly positive in BPH. High survivin expression is related to a higher Gleason score in the adenocarcinoma of the prostate.
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Affiliation(s)
- Mansooreh Eslami
- Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran
| | - Tahere Khamechian
- Anatomical Science Research Center, Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran
| | - Tahere Mazoochi
- Gametogenese Research Center, Kashan University of Medical Sciences, 5th Km Qotbe Ravandi Blv, Kashan, Islamic Republic of Iran
| | - Hasan Ehteram
- Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran
| | - Mojtaba Sehat
- Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran
| | - Javad Alizargar
- Student Research Committee, Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran
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