Younger Men With Prostate Cancer Have Lower Risk of Upgrading While on Active Surveillance: A Meta-analysis and Systematic Review of the Literature

Interaction of patient age and high-grade prostate cancer on targeted biopsies of MRI suspicious lesions

OBJECTIVES

To evaluate the interaction of patient age and Prostate Imaging-Reporting and Data System (PI-RADS) score in determining the grade of prostate cancer (PCa) identified on magnetic resonance imaging (MRI)-targeted biopsy in older men.

PATIENTS AND METHODS

From a prospectively accrued Institutional Review Board-approved comparative study of MRI-targeted and systematic biopsy between June 2012 and December 2022, men with at least one PI-RADS ≥3 lesion on pre-biopsy MRI and no prior history of PCa were selected. Ordinal and binomial logistic regression analyses were performed.

RESULTS

A total of 2677 men met study criteria. The highest PI-RADS score was 3 in 1220 men (46%), 4 in 950 men (36%), and 5 in 507 men (19%). The median (interquartile range [IQR]) patient age was 66.7 (60.8-71.8) years, median (IQR) prostate-specific antigen (PSA) level was 6.1 (4.6-9.0) ng/mL, median (IQR) prostate volume was 48 (34-68) mL, and median (IQR) PSA density was 0.13 (0.08-0.20) ng/mL/mL. Clinically significant (cs)PCa and high-risk PCa were identified on targeted biopsy in 1264 (47%) and 321 (12%) men, respectively. Prevalence of csPCa and high-risk PCa were significantly higher in the older age groups. On multivariable analyses, patient age was significantly associated with csPCa but not high-risk PCa; PI-RADS score and the interaction of age and PI-RADS score were significantly associated with high-risk PCa but not csPCa.

CONCLUSION

In our cohort, the substantial rate of high-risk PCa on MRI-ultrasound fusion targeted biopsies in older men, and its significant association with MRI findings, supports the value of pre-biopsy MRI to localise disease that could cause cancer mortality even in older men.

Active Surveillance for Men Younger than 60 Years or with Intermediate-risk Localized Prostate Cancer. Descriptive Analyses of Clinical Practice in the Movember GAP3 Initiative

Background

Active surveillance (AS) is a management option for men diagnosed with low-risk prostate cancer. Opinions differ on whether it is safe to include young men (≤60 yr) or men with intermediate-risk disease.

Objective

To assess whether reasons for discontinuation, treatment choice after AS, and adverse pathology at radical prostatectomy (RP; N1, or ≥GG3, or ≥pT3) differ for men ≤60 yr or those with European Association of Urology (EAU) intermediate-risk disease from those for men >60 yr or those with EAU low-risk disease.

Design setting and participants

We analyzed data from 5411 men ≤60 yr and 14 959 men >60 yr, 14 064 men with low-risk cancer, and 2441 men with intermediate-risk cancer, originating from the GAP3 database (21 169 patients/27 cohorts worldwide).

Outcome measurements and statistical analysis

Cumulative incidence curves were used to estimate the rates of AS discontinuation and treatment choice.

Results and limitations

The probability of discontinuation of AS due to disease progression at 5 yr was similar for men aged ≤60 yr (22%) and those >60 yr (25%), as well as those of any age with low-risk disease (24%) versus those with intermediate-risk disease (24%). Men with intermediate-risk disease are more prone to discontinue AS without evidence of progression than men with low-risk disease (at 1/5 yr: 5.9%/14.2% vs 2.0%/8.8%). Adverse pathology at RP was observed in 32% of men ≤60 yr compared with 36% of men >60 yr (p = 0.029), and in 34% with low-risk disease compared with 40% with intermediate-risk disease (p = 0.048).

Conclusions

Our descriptive analysis of AS practices worldwide showed that the risk of progression during AS is similar across the age and risk groups studied. The proportion of adverse pathology was higher among men >60 yr than among men ≤60 yr. These results suggest that men ≤60 yr and those with EAU intermediate-risk disease should not be excluded from opting for AS as initial management.

Patient summary

Data from 27 international centers reflecting daily clinical practice suggest that younger men or men with intermediate-risk prostate cancer do not hold greater risk for disease progression during active surveillance.

The added influence of genomics and post-MRI confirmatory biopsy results to MRI results alone on medical decision making for men with favorable risk prostate cancer being considered for active surveillance

BACKGROUND

We examined how the results of genomic classifier (GC) or post-magnetic resonance imaging confirmatory biopsy (pMRI-CBx) influenced management strategy for men with an MRI considering active surveillance (AS).

METHODS

We reviewed the Michigan Urological Surgery Improvement Collaborative registry for men with favorable-risk prostate cancer. Among men with an MRI after the diagnostic biopsy (n = 1162) a subset also had GC (n = 126) or pMRI-CBx (n = 309). Results of MRI, GC, and pMRI-CBx were deemed reassuring (RA) or non-reassuring (Non-RA). We assess the association of the combination of test results obtained with the selection of AS. Proportions were compared with the Fisher's exact test. Multivariable logistic regression models were fit for an association of test results with the selection of AS.

RESULTS

The results of pMRI-CBx tended to influence management decisions greater than that of GC, especially in situation where testing results were discordant with the MRI result. Fewer men with a RA MRI and non-RA pMRI-CBx where managed with AS compared with RA MRI alone (31% vs. 86%, p < 0.001). non-RA genomics did not seem to have the same influence on management as non-RA pMRI-CBx as a similar proportion of men with RA MRI and non-RA genomics were managed with AS compared with RA MRI alone (85% vs. 86%, p = 0.753). More men with non-RA MRI and RA pMRI-CBx were managed with AS compared with non-RA MRI alone (89% vs. 40%, p < 0.001). Alternatively, a similar proportion of men with non-RA MRI and RA genomics were managed with AS compared with non-RA MRI alone (42% vs. 40%, p > 0.999). In the multivariable models, pMRI-CBx results influenced the decision for AS versus treatment.

CONCLUSIONS

In men with newly diagnosed prostate cancer and an MRI, the additional information provided by pMRI-CBx influenced the decision of AS versus treatment, while the addition of GC results were less influential.

Urologists' Perceptions of Active Surveillance and Their Recommendations for Low-risk Prostate Cancer Patients

OBJECTIVE

To assess practicing urologists' attitudes and perceptions of active surveillance (AS) and other treatment options for low-risk prostate cancer.

METHODS

This was a cross-sectional survey of urologists practicing in Michigan and Georgia. Urologists were asked about perceptions and practices pertaining to AS.

RESULTS

Overall, 225 urologists completed the survey; 147 (65%) were from Michigan and 78 (35%) were from Georgia. Most urologists reported they provided (99%), discussed (97%), and offered (61%) AS to all of their low-risk patients. Most believed AS is effective (97%) and underused (90%), while 80% agreed that curative therapy (surgery, radiation) is overused in the United States. Although most (79%) endorse that Black men are more likely to have aggressive low-risk disease, 89% reported feeling comfortable recommending AS to Black men. In multivariable analysis, significant provider-related predictors of AS recommendation were practice location, number of years in practice, beliefs pertaining to survival benefit of prostatectomy and effectiveness of AS, and expectation that patients are not interested in AS. The patient characteristics of race, age, life expectancy, fear of cancer progression, and fear of treatment side effects were also significant predictors of AS recommendations.

CONCLUSION

Most urologists surveyed stated that AS is effective and underused for low-risk prostate cancer . Overall, urologists are much less likely to recommend AS to younger men and slightly less to Black men. AS recommendations varied by practice location and by years in practice. These findings indicate targeted educational efforts in the US are needed to influence urologists toward greater acceptance of AS.

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.

Impact of biopsy perineural invasion on younger prostate cancer patients after radical prostatectomy

OBJECTIVES

To identify the potential indicators for higher-risk disease and poor outcome in younger prostate cancer (PCa) patients (age ≤ 50) who had undergone radical prostatectomy (RP) in the prostate-specific antigen (PSA) era.

MATERIALS AND METHODS

A total of 186 PCa cases of age ≤ 50 who underwent RP between 2003 and 2010 at our center were included for study. High-risk disease after RP was defined as cases with pre-PSA ≥ 20 ng/ml and/or Gleason score (GS) ≥ 4 + 3 and/or pT stage ≥ 3. The poor outcome group was defined as cases with biochemical recurrence (BCR) and/or metastasis (Mets) and/or all-cause death. Multivariate logistic regression models were performed to identify independent risk factors for both high-risk disease and poor outcome.

RESULTS

Among 186 younger PCa patients aged ≤ 50, 36 cases (19.5%) had high-risk disease and 24 cases (12.9%) had poor outcome. The presence of biopsy perineural invasion (BxPNI) was significantly associated with high-risk disease and showed a trend to correlate with worse outcome in univariate analysis. On multivariate logistic regression analysis, BxPNI was shown to be a significant independent risk factor with covariate of D'Amico for poor outcome (p = 0.047) and an independent risk factor with covariate of BxGPC for high-risk PCa excepting the variables to define high-risk disease (p = 0.013). Prognostically, cases with BxPNI showed a poor BCR-free survival in univariate analysis but did not reach significance (p = 0.063).

CONCLUSION

Our results show that BxPNI could be considered as a risk classification factor to identify the best candidates among younger PCa patients for further treatment and may also be used for developing active surveillance (AS) selection criteria for younger PCa patients.

Clinicopathological characteristics of localized prostate cancer in younger men aged ≤ 50 years treated with radical prostatectomy in the PSA era: A systematic review and meta-analysis

Objectives

With the rapid increase in younger age prostate cancer (PCa) patients, the impact of younger age on decision‐making for PCa treatment needs to be revaluated in the new era.

Materials and Methods

A systematic literature search was performed using PubMed, EMBASE, and Web of Science up to October 2019 to identify the eligible radical prostatectomy (RP) studies focusing on understanding the impact of age on clinicopathological features and oncological prognosis in patients with localized PCa in PSA era. Meta‐analyses were conducted using available hazard ratios (HRs) from both univariate and multivariate analyses.

Results

Twenty‐six studies including 391 068 patients with RP treatments from the PSA era were included. Of these studies, age of 50 years old (age50) is the most commonly used cut‐off age to separate the younger patient group (including either age < 50 or age ≤ 50) from the older patient group. In these studies, the incidence of younger patients varied between 2.6% and 16.6% with a median of 8.3%. Younger patients consistently showed more favorable clinicopathological features correlated with better BCR prognosis. Meta‐analyses showed a 1.38‐fold improved BCR survival of younger patients in multivariate analysis. Among the high‐risk PCa patients, younger age was independently associated with worse oncological outcomes in multivariate analyses.

Conclusion

In this study, we found younger age correlated with favorable clinicopathological characteristics and better BCR prognosis in low‐ to intermediate‐risk patients. In high‐risk group patients, younger patients often showed significantly worse oncological outcomes. Our study results suggest that age 50 could be used as a practical cut‐off age to separate younger age patients from older age PCa patients.