Active surveillance for localized prostate cancer: update of a prospective single-center cohort

Japanese clinical practice guidelines for prostate cancer 2023

This fourth edition of the Japanese Clinical Practice Guidelines for Prostate Cancer 2023 is compiled. It was revised under the leadership of the Japanese Urological Association, with members selected from multiple academic societies and related organizations (Japan Radiological Society, Japanese Society for Radiation Oncology, the Department of EBM and guidelines, Japan Council for Quality Health Care (Minds), Japanese Society of Pathology, and the patient group (NPO Prostate Cancer Patients Association)), in accordance with the Minds Manual for Guideline Development (2020 ver. 3.0). The most important feature of this revision is the adoption of systematic reviews (SRs) in determining recommendations for 14 clinical questions (CQs). Qualitative SRs for these questions were conducted, and the final recommendations were made based on the results through the votes of 24 members of the guideline development group. Five algorithms based on these results were also created. Contents not covered by the SRs, which are considered textbook material, have been described in the general statement. In the general statement, a literature search for 14 areas was conducted; then, based on the general statement and CQs of the Japanese Clinical Practice Guidelines for Prostate Cancer 2016, the findings revealed after the 2016 guidelines were mainly described. This article provides an overview of these guidelines.

Comparison of Outcomes of Active Surveillance in Intermediate-Risk Versus Low-Risk Localised Prostate Cancer Patients: A Systematic Review and Meta-Analysis

Currently, there is no clear consensus regarding the role of active surveillance (AS) in the management of intermediate-risk prostate cancer (IRPC) patients. We aim to analyse data from the available literature on the outcomes of AS in the management of IRPC patients and compare them with low-risk prostate cancer (LRPC) patients. A comprehensive literature search was performed, and relevant data were extracted. Our primary outcome was treatment-free survival, and secondary outcomes were metastasis-free survival, cancer-specific survival, and overall survival. The DerSimonian–Laird random-effects method was used for the meta-analysis. Out of 712 studies identified following an initial search, 25 studies were included in the systematic review. We found that both IRPC and LRPC patients had nearly similar 5, 10, and 15 year treatment-free survival rate, 5 and 10 year metastasis-free survival rate, and 5 year overall survival rate. However, cancer-specific survival rates at 5, 10, and 15 years were significantly lower in IRPC compared to LRPC group. Furthermore, IRPC patients had significantly inferior long-term overall survival rate (10 and 15 year) and metastasis-free survival rate (15 year) compared to LRPC patients. Both the clinicians and the patients can consider this information during the informed decision-making process before choosing AS.

A national questionnaire survey of Japanese urologists on active surveillance for low- and intermediate-risk prostate cancer

OBJECTIVE

To conduct a national questionnaire survey of Japanese urologists on active surveillance (AS) for low- and intermediate-risk prostate cancer (PCa).

METHODS

A questionnaire was sent to 922 Japanese Urological Association Teaching Base Hospitals. The items included were years of experience as a urologist, sex, workplace, treatment equipment owned, specialty area of daily practice, specialty area of urological cancer, and six hypothetical cases of AS. The cases were categorized by the following Gleason scores: 3 + 3 low risk of PCa, 3 + 4 intermediate risk, and 4 + 3 intermediate risk, with or without comorbidities for each case. Comorbidities were defined as cardiovascular diseases or illnesses warranting anticoagulant therapy.

RESULTS

Altogether, 1962 questionnaires were analyzed. Responses were almost equally distributed among all age groups. Workplaces included general hospitals (49.4%), university hospitals (40.3%), and cancer centers (4.2%). Percentages of proposed AS for low risk/no comorbidity, low risk/with comorbidity, intermediate-risk 3 + 4/no comorbidity, intermediate risk 3 + 4/with comorbidity, intermediate risk 4 + 3/no comorbidity, and intermediate risk 4 + 3/with comorbidity were 90.5%, 90%, 39.5%, 48.7%, 15%, and 22%, respectively. Analysis of the correspondents' backgrounds showed that the more the urologists' years of experience, the less they were to advise AS of low-risk patients. In the presence of comorbidities, urologists across all age groups tended to propose AS, even in the same Gleason grade group. Cancer center urologists recommended AS more often than their counterparts at general and university hospitals.

CONCLUSIONS

Approximately 40% of urologists proposed AS for intermediate-risk cases, confirming that AS for intermediate-risk patients is being considered in Japan.

Establishment of Prospective Registry of Active Surveillance for Prostate Cancer: The Korean Urological Oncology Society Database

PURPOSE

To establish a prospective registry for the active surveillance (AS) of prostate cancer (PC) using the Korean Urological Oncology Society (KUOS) database and to present interim analysis.

MATERIALS AND METHODS

The KUOS registry of AS for PC (KUOS-AS-PC) was organized in May 2019 and comprises multiple institutions nationwide. The eligibility criteria were as follows: patients with (1) pathologically proven PC; (2) pre-biopsy prostate-specific antigen (PSA) ≤20 ng/mL; (3) International Society of Urological Pathology (ISUP) grade 1 or 2 (no cribriform pattern 4); (4) clinical T stage ≤T2c; (5) positive core ratio ≤50%; and (6) maximal cancer involvement in the core ≤50%. Detailed longitudinal clinical information, including multi-parametric magnetic resonance imaging and disease-specific outcomes, was recorded.

RESULTS

From May 2019 to June 2021, 296 patients were enrolled, and 284 were analyzed. The mean±standard deviation (SD) age at enrollment was 68.7±8.2 years. The median follow-up period was 11.2 months (5.9-16.8 mo). Majority of patients had pre-biopsy PSA ≤10 ng/mL (91.2%), PSA density <0.2 ng/mL² (79.7%), ISUP grade group 1 (94.4%), single positive core (65.7%), maximal cancer involvement in the core ≤20% (78.1%), and clinical T stage of T1c or lower (72.9%). Fifty-two (18.3%) discontinued AS for various reasons. Interventions included radical prostatectomy (80.8%), transurethral prostatectomy (5.8%), primary androgen deprivation therapy (5.8%), radiation (5.8%), and focal therapy (1.9%). The mean±SD time to intervention was 8.9±5.2 months. The reasons for discontinuation included pathologic reclassification (59.6%), patient preference (25.0%), and radiologic reclassification (9.6%). Two (4.8%) patients with pathologic Gleason score upgraded to ISUP grade group 4, no biochemical recurrence.

CONCLUSIONS

The KUOS established a successful prospective database of PC patients undergoing AS in Korea, named the KUOS-AS-PC registry.

Active Surveillance for Intermediate-risk Prostate Cancer: A Systematic Review, Meta-analysis, and Metaregression

CONTEXT

Active surveillance (AS) is increasingly selected among patients with localized, intermediate-risk (IR) prostate cancer (PCa). However, the safety and optimal candidate selection for those with IR PCa remain uncertain.

OBJECTIVE

To evaluate treatment-free survival and oncologic outcomes in patients with IR PCa managed with AS and to compare with AS outcomes in low-risk (LR) PCa patients.

EVIDENCE ACQUISITION

A literature search was conducted through February 2022 using PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed to identify eligible studies. The coprimary outcomes were treatment-free, metastasis-free, cancer-specific, and overall survival. A subgroup analysis was planned a priori to explore AS outcomes when limiting inclusion to IR patients with a Gleason grade (GG) of ≤2.

EVIDENCE SYNTHESIS

A total of 25 studies including 29 673 unselected IR patients met our inclusion criteria. The 10-yr treatment-free, metastasis-free, cancer-specific, and overall survival ranged from 19.4% to 69%, 80.8% to 99%, 88.2% to 99%, and 59.4% to 83.9%, respectively. IR patients had similar treatment-free survival to LR patients (risk ratio [RR] 1.16, 95% confidence interval (CI), 0.99-1.36, p = 0.07), but significantly higher risks of metastasis (RR 5.79, 95% CI, 4.61-7.29, p < 0.001), death from PCa (RR 3.93, 95% CI, 2.93-5.27, p < 0.001), and all-cause death (RR 1.44, 95% CI, 1.11-1.86, p = 0.005). In a subgroup analysis of studies including patients with GG ≤2 only (n = 4), treatment-free survival (RR 1.03, 95% CI, 0.62-1.71, p = 0.91) and metastasis-free survival (RR 2.09, 95% CI, 0.75-5.82, p = 0.16) were similar between LR and IR patients. Treatment-free survival was significantly reduced in subgroups of patients with unfavorable IR disease and increased cancer length on biopsy.

CONCLUSIONS

The present systematic review and meta-analysis highlight the need to optimize patient selection for those with IR features. Our findings support limiting the inclusion of IR patients in AS to those with low-volume GG 2 tumor.

PATIENT SUMMARY

Active surveillance is increasingly used in patients with localized, intermediate-risk (IR) prostate cancer. In this population, we have reported higher risks of metastasis and cancer mortality in unselected patients than in patients with low-risk features, underscoring the need to optimize the selection of patients with IR features.

Active Surveillance in Intermediate-Risk Prostate Cancer: A Review of the Current Data

Simple Summary

AS is an option for the initial management of selected patients with intermediate-risk PC. The proper way to predict which men will have an aggressive clinical course or indolent PC who would benefit from AS has not been unveiled. Genetics and MRI can help in the decision-making, but it remains unclear which men would benefit from which tests. In addition, there are several differences between AS protocols in inclusion criteria, monitoring follow-up, and triggers for active treatment. Large series and a few RCTs are under investigation, and more research is needed to establish an optimal therapeutic strategy for patients with intermediate-risk PC. This study summarizes the current data on patients with intermediate-risk PC under AS, recent findings, and discusses future directions.

Abstract

Active surveillance (AS) is a monitoring strategy to avoid or defer curative treatment, minimizing the side effects of radiotherapy and prostatectomy without compromising survival. AS in intermediate-risk prostate cancer (PC) has increasingly become used. There is heterogeneity in intermediate-risk PC patients. Some of them have an aggressive clinical course and require active treatment, while others have indolent disease and may benefit from AS. However, intermediate-risk patients have an increased risk of metastasis, and the proper way to select the best candidates for AS is unknown. In addition, there are several differences between AS protocols in inclusion criteria, monitoring follow-up, and triggers for active treatment. A few large series and randomized trials are under investigation. Therefore, more research is needed to establish an optimal therapeutic strategy for patients with intermediate-risk disease. This study summarizes the current data on patients with intermediate-risk PC under AS, recent findings, and discusses future directions.

Secondary Treatment for Men with Localized Prostate Cancer: A Pooled Analysis of PRIAS and ERSPC-Rotterdam Data within the PIONEER Data Platform

Introduction: Treatment choice for localized prostate cancer is complicated, as each treatment option comes with various pros and cons. It is well established that active surveillance (AS), may be ended with a change to curative treatment at the time of disease progression, but it is less clear whether secondary treatment after initial curative treatment is required. As part of the PIONEER project, we quantified the probabilities of treatment change. Methods: A cohort study based on PRIAS and ERSPC-Rotterdam data was conducted. Patients were followed up for 10 years or until the 31st of December 2017. The primary outcome was the incidence of treatment change following initial treatment (i.e., a change to curative treatment following AS or secondary treatment after initial RP/RT). Results: Over a period of 1 to 5 years after initial treatment, the cumulative incidence of treatment change ranged from 3.8% to 42.8% for AS, from 7.6% to 12.1% for radical prostatectomy (RP) and from no change to 5.3% for radiation therapy (RT). While the possibility of treatment change in AS is known, the numbers within a five-year period were substantial. For RP and RT, the rate of change to secondary treatment was lower, but still non-neglectable, with 5 (10)-year incidences up to 12% (20%) and 5% (16%), respectively. Conclusion: This is one of the first studies comparing the incidence of guideline-recommended treatment changes in men receiving different primary treatments (i.e., AS, RT, or RP) for localized prostate cancer (PCa).

Active surveillance for intermediate-risk prostate cancer

INTRODUCTION

Active surveillance (AS) is an established approach in the management of low-risk, localized prostate cancer. While the use of AS to manage intermediate-risk (IR) disease has gradually increased over time, there remains uncertainty with regards to its safety, with only a minority of IR patients currently being managed with this approach.

MATERIALS AND METHODS

We conducted a narrative review based on an analysis of the literature focusing on articles describing AS for IR prostate cancer. We focus on the uncertainty surrounding AS in IR disease by discussing variations in the definitions and guideline recommendations associated with IR disease, and describing the limitations of the evidence from observational studies and randomized trials.

CONCLUSION

The safety of AS for IR disease remains unknown, given the lack of randomized trials and the limitations of the current observational studies. Further research is needed to identify select patients with IR prostate cancer that can be managed safely with AS.

Active Surveillance-Is It Feasible for Intermediate-risk Localised Prostate Cancer?

Background

Although active surveillance (AS) is a well-recognised treatment option for localised low-risk prostate cancer (LRPC), its role in the management of localised intermediate-risk prostate cancer (IRPC) is not clear yet and the available literature is slightly contradictory.

Objective

To compare the outcome of AS between LRPC and IRPC patients.

Design, setting, and participants

Between November 2002 and August 2019, 372 men with localised prostate cancer (PC) underwent AS in our hospital based on local departmental protocol.

Outcome measurements and statistical analysis

The primary outcome measures were overall survival, disease progression–free survival, treatment-free survival, and biochemical recurrence–free survival. Survival times in the low- and intermediate-risk groups were compared using Cox regression analysis.

Results and limitations

Out of 372 localised PC patients, 276 (74%) had LRPC and 96 (26%) IRPC. Overall, 86 (31.2%) low-risk and 25 (26%) intermediate-risk patients developed disease progression, and 86 (31.2%) low-risk and 22 (23%) intermediate-risk patients underwent active treatment. Among the treated patients, eight (2.9%) LRPC patients and one (1%) IRPC patient developed biochemical recurrence. In total, only one patient (from the low-risk group) had metastasis and 25 patients passed away (18 from the low-risk and seven from the intermediate-risk group). No death was recorded due to PC in the cohort. There was no difference in any of the survival outcomes between LRPC and IRPC patients in unadjusted analysis as well as when analysis was performed after adjusting the potentially confounding factors. Limitations include relatively short median follow-up time and failure to objectively define the criteria for the selection of IRPC patients suitable for AS.

Conclusions

The option of AS could be considered for carefully selected and well-informed patients with IRPC provided close structured monitoring is maintained.

Patient summary

In this report, we looked at various survival outcomes of active surveillance between low- and intermediate-risk prostate cancer patients in a large British population. There was no difference in any of the survival outcomes between the two groups. We concluded that carefully selected intermediate-risk prostate cancer patients could be offed the option of active surveillance.

Active Surveillance for Intermediate-Risk Prostate Cancer: Systematic Review and Meta-analysis of Current Protocols and Outcomes

INTRODUCTION

Current guidelines allow active surveillance for intermediate-risk prostate cancer patients but do not provide comprehensive recommendations for selection. We performed a systematic review and meta-analysis of outcomes for active surveillance in intermediate- and low-risk groups.

METHODS

We performed a systematic literature search of intermediate-risk localized prostate cancer patients undergoing active surveillance using 3 literature search engines (Medline, Web of Science, and Scopus) over the past 10 years. The primary outcome was the percentage of patients who remain under surveillance. Secondary outcomes included cancer-specific survival, overall survival, and metastasis-free survival. For articles including both low- and intermediate-risk patients undergoing active surveillance, comparisons between the two groups were made.

RESULTS

The proportion of patients who remained on active surveillance was comparable between the low- and intermediate-risk groups after 10 and 15 years' follow-up (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.83-1.14; and OR, 0.86; 95% CI, 0.65-1.13). Cancer-specific survival was worse in the intermediate-risk group after 10 years (OR, 0.47; 95% CI, 0.31-0.69) and 15 years (OR, 0.34; 95% CI, 0.2-0.58). The overall survival rate showed no statistical difference at 5 years' follow-up (OR, 0.84; 95% CI, 0.45-1.57) but was worse in the intermediate-risk group after 10 years (OR, 0.43; 95% CI, 0.35-0.53). Metastases-free survival did not significantly differ after 5 years (OR, 0.55; 95% CI, 0.2-1.53) and was worse in the intermediate-risk group after 10 years (OR, 0.46; 95% CI, 0.28-0.77).

CONCLUSION

Active surveillance could be offered to patients with intermediate-risk prostate cancer. However, they should be informed of the need for regular monitoring and the possibility of discontinuation as a result of a higher rate of progression. Available data indicate that 5-year survival rates between intermediate- and low-risk patients do not differ; 10-year survival rates are worse. To assess the long-term effectiveness and safety of active surveillance, it is necessary to develop unified algorithms for patient selection and management, and to prospectively conduct studies with long-term surveillance.

Active surveillance for intermediate-risk prostate cancer: yes, but for whom?

PURPOSE OF REVIEW

Active surveillance is becoming more widely accepted as an initial management option for carefully selected men with favorable intermediate-risk prostate cancer (PCa). As prospective active surveillance cohorts mature sufficiently to begin evaluating longer-term outcomes, consensus on more precise evidence-based guidelines is needed to identify the patient cohorts who may be safely managed with active surveillance and what the ideal surveillance protocol entails.

RECENT FINDINGS

Long-term outcomes updates have suggested a trend toward worse 15-year survival outcomes for intermediate-risk patients on active surveillance compared with definitive treatment, but 'intermediate-risk' is a broad category and there is a subset of favorable intermediate-risk patients for whom survival outcomes remain equivalent. Promising updates to current risk stratification include consideration of genomic classifiers, advanced imaging and more nuanced interpretation of biopsy results.

SUMMARY

Despite widespread acknowledgement of the pitfalls of overtreatment in clinically localized PCa, utilization of active surveillance in the intermediate-risk population remains marginal, in part due to the absence of easily interpretable consensus recommendations. As more long-term outcomes data become available for this subgroup, the field is now poised to refine the definition of favorable intermediate-risk patients for whom active surveillance is a safe, evidence-based first-line management option.

Defining and Measuring Adherence in Observational Studies Assessing Outcomes of Real-world Active Surveillance for Prostate Cancer: A Systematic Review

CONTEXT

Evidence-based guidelines for active surveillance (AS), a treatment option for men with low-risk prostate cancer, recommend regular follow-up at periodic intervals to monitor disease progression. However, gaps in monitoring can lead to delayed detection of cancer progression, leading to a missed window of curability.

OBJECTIVE

We aimed to identify the extent to which real-world observational studies reported adherence to monitoring protocols among prostate cancer patients on AS. When reported, we sought to characterize definitions of adherence.

EVIDENCE ACQUISITION

We systematically reviewed observational studies assessing outcomes of prostate cancer patients on AS, published before March 22, 2019 in PubMed, Embase, and CENTRAL. Adherence definitions were considered time bound if they included prespecified time and binary if adherence was assessed but did not specify a time interval. We assessed study quality using the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

EVIDENCE SYNTHESIS

Forty-five studies met our inclusion criteria. Eleven studies did not report any data on adherence to AS protocols. Twenty-five studies did not explicitly measure adherence, but provided relevant data (eg, number of patients who received a repeat biopsy). Six studies reported adherence using a time-bound definition, while three studies used a binary definition. Twenty-three studies provided information on patients lost to follow-up.

CONCLUSIONS

Most studies reporting outcomes of patients on AS did not measure or report adherence. When reported, adherence was often not time specific. As some AS patients will benefit from maintaining a window of curability, clinical practices and future studies should track and report adherence and associated factors.

PATIENT SUMMARY

We reviewed real-world observational studies examining outcomes of prostate cancer patients on active surveillance. Most studies did not clearly define or report adherence to monitoring protocols, which is important to consider for appropriate disease management.