Factors Associated with Time to Conversion from Active Surveillance to Treatment for Prostate Cancer in a Multi-Institutional Cohort

Active Surveillance for Taiwanese Men with Localized Prostate Cancer: Intermediate-Term Outcomes and Predictive Factors

PURPOSE

Active surveillance (AS) is one of the management options for patients with low-risk and select intermediate-risk prostate cancer (PC). However, factors predicting disease reclassification and conversion to active treatment from a large population of pure Asian cohorts regarding AS are less evaluated. This study investigated the intermediate-term outcomes of patients with localized PC undergoing AS.

MATERIALS AND METHODS

This cohort study enrolled consecutive men with localized non-high-risk PC diagnosed in Taiwan between June 2012 and Jan 2023. The study endpoints were disease reclassification (either pathological or radiographic progression) and conversion to active treatment. The factors predicting endpoints were evaluated using the Cox proportional hazards model.

RESULTS

A total of 405 patients (median age: 67.2 years) were consecutively enrolled and followed up with a median of 64.6 months. Based on the National Comprehensive Cancer Network (NCCN) risk grouping, 70 (17.3%), 164 (40.5%), 140 (34.6%), and 31 (7.7%) patients were classified as very low-risk, low-risk, favorable-intermediate risk, and unfavorable intermediate-risk PC, respectively. The 5-year reclassification rates were 24.8%, 27.0%, 18.6%, and 25.3%, respectively. The 5-year conversion rates were 20.4%, 28.8%, 43.6%, and 37.8%, respectively. A prostate-specific antigen density (PSAD) of ≥0.15 ng/mL² predicted reclassification (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.17-2.88) and conversion (HR 1.56, 95% CI 1.05-2.31). A maximal percentage of cancer in positive cores (MPCPC) of ≥15% predicted conversion (15% to <50%: HR 1.41, 95% CI 0.91-2.18; ≥50%: HR 1.97, 95% CI 1.1453-3.40) compared with that of <15%. A Gleason grade group (GGG) of 3 tumor also predicted conversion (HR 2.69, 95% CI 1.06-6.79; GGG 3 vs 1). One patient developed metastasis, but none died of PC during the study period (2,141 person-years).

CONCLUSIONS

AS is a viable option for Taiwanese men with non-high-risk PC, in terms of reclassification and conversion. High PSAD predicted reclassification, whereas high PSAD, MPCPC, and GGG predicted conversion.

Incorporating Genetic Risk Into Prostate Cancer Care: Implications for Early Detection and Precision Oncology

The availability and cost of germline and somatic genetic testing have dramatically improved over the past two decades, enabling precision medicine approaches in oncology, with significant implications for prostate cancer (PCa) care. Roughly 12% of individuals with advanced disease are carriers of rare pathogenic germline variants that predispose to particularly aggressive and earlier-onset disease. Several of these variants are already established as clinically actionable by modern precision oncology therapeutics, while others may come to aid the selection of active surveillance, definitive local therapies, and systemic therapies. Concurrently, the number of common variants (ie, incorporated into polygenic risk scores) associated with PCa risk has continued to grow, but with several important considerations both at the intersection of race and ancestry and for early detection of aggressive disease. Family history has historically been used as a proxy for this inherited genetic risk of PCa, but recently emerging evidence examining this relation has shifted our understanding of how best to leverage this tool in PCa care. This review seeks to clarify and contextualize the existing and emerging precision oncology paradigms that use inherited genetic risk in PCa care, for both early detection and localized disease management.

Patient perspectives on factors influencing active surveillance adherence for low-risk prostate cancer: A qualitative study

BACKGROUND

Prostate cancer is the most common cancer among men in the United States. Treatment guidelines recommend active surveillance for low-risk prostate cancer, which involves monitoring for progression, to avoid or delay definitive treatments and their side effects. Despite increased uptake, adherence to surveillance remains a challenge.

METHODS

We conducted semi-structured, qualitative, virtual interviews based on the Theoretical Domains Framework (TDF), with men (15) who were or had been on active surveillance for their low-risk prostate cancer in 2020. Interviews were transcribed and coded under TDF's behavioral theory-based domains. We analyzed domains related to adherence to surveillance using constructivist grounded theory to identify themes influencing decision processes in adherence.

RESULTS

The TDF domains of emotion, beliefs about consequences, environmental context and resources, and social influences were most relevant to surveillance adherence-. From these four TDF domains, three themes emerged as underlying decision processes: trust in surveillance as treatment, quality of life, and experiences of self and others. Positive perceptions of these three themes supported adherence while negative perceptions contributed to non-adherence (i.e., not receiving follow-up or stopping surveillance). The relationship between the TDF domains and themes provided a theoretical process describing factors impacting active surveillance adherence for men with low-risk prostate cancer.

CONCLUSIONS

Men identified key factors impacting active surveillance adherence that provide opportunities for clinical implementation and practice improvement. Future efforts should focus on multi-level interventions that foster trust in surveillance as treatment, emphasize quality of life benefits and enhance patients' interpersonal experiences while on surveillance to optimize adherence.

Aggressive Prostate Cancer in Patients Treated with Active Surveillance

Active surveillance has emerged as a promising approach for managing low-risk and favorable intermediate-risk prostate cancer (PC), with the aim of minimizing overtreatment and maintaining the quality of life. However, concerns remain about identifying "aggressive prostate cancer" within the active surveillance cohort, which refers to cancers with a higher potential for progression. Previous studies are predictors of aggressive PC during active surveillance. To address this, a personalized risk-based follow-up approach that integrates clinical data, biomarkers, and genetic factors using risk calculators was proposed. This approach enables an efficient risk assessment and the early detection of disease progression, minimizes unnecessary interventions, and improves patient management and outcomes. As active surveillance indications expand, the importance of identifying aggressive PC through a personalized risk-based follow-up is expected to increase.

Use of expectant management based on prostate cancer risk and health status: How far are we from a risk-adapted approach?

OBJECTIVES

While active surveillance, a form of expectant management (EM), is preferred for patients with low-risk prostate cancer (PCa), some favor a more risk-adapted approach that recognizes patient preferences and condition-specific factors. However, previous research has shown non-patient-related factors often drive PCa treatment. In this context, we characterized trends in AS with respect to disease risk and health status.

METHODS AND MATERIALS

Using SEER-Medicare data, we identified men 66 years and older diagnosed with localized low- and intermediate-risk PCa from 2008 to 2017 and examined receipt of EM, defined as the absence of treatment (i.e., surgery, cryotherapy, radiation, chemotherapy, and androgen deprivation therapies) within 1 year of diagnosis. We performed bivariable analysis to compare trends in use for EM vs. treatment, stratified by disease risk (i.e., Gleason 3+3, 3+4, 4+3; PSA<10, 10-20) and health status (i.e., NCI Comorbidity Index (NCI), frailty, life expectancy). We then ran a multivariable logistic regression model to examine determinants of EM.

RESULTS

Within this cohort, 26,364 (38%) were categorized as low-risk (i.e., Gleason 3+3 and PSA<10) and 43,520 (62%) as intermediate-risk (i.e., all others). Over the study period, use of EM significantly increased across all risk groups, except for Gleason 4+3 (P = 0.662), as well across all health status groups. However, linear trends did not differ significantly between frail vs. nonfrail patients for both those categorized as low-risk (P = 0.446) and intermediate-risk (P = 0.208). Trends also did not differ between NCI 0 vs. 1 vs. >1 for low-risk PCa (P = 0.395). In the multivariable models, EM was associated with increasing age and being frail for men with both low- and intermediate risk disease. Conversely, EM selection was negatively associated with higher comorbidity score.

CONCLUSIONS

EM increased significantly over time for patients with low- and favorable intermediate-risk disease, with the most notable differences based on age and Gleason score. In contrast, trends in uptake of EM did not differ substantively by health status, suggesting that physicians may not be effectively incorporating patient health into PCa treatment decisions. Additional work is needed to develop interventions that recognize health status as an essential component of a risk-adapted approach.

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.

Low risk is low risk, regardless of race or ethnicity: Outcomes of prostate cancer active surveillance and factors associated with reclassification in a racially diverse cohort

INTRODUCTION

Active surveillance (AS) is the standard for very low- and low-risk prostate cancer. Although risk factors for pathologic reclassification while on AS have been identified, results are mixed for non-Hispanic Black (NHB) and Hispanic ethnicity. We aim to further explore how race and ethnicity may be affecting AS participation and outcomes in a primarily urban, diverse, and vulnerable population.

MATERIALS AND METHODS

Patients eligible for AS from 2005-2020 were reviewed. Demographics, race/ethnicity, prostate specific antigen (PSA), prostate volume, and pathologic characteristics were analyzed between patients enrolled in AS and those that underwent immediate therapy. Kaplan-Meier survival analysis was used to compare biochemical recurrence (BCR) rates. Cox proportional hazards models were used to develop prediction models for clinical reclassification.

RESULTS

A total of 471 men were eligible for AS. Of those, 188 (39.9%) enrolled in AS while 283 (60.1%) underwent immediate radical therapy. No significant differences were found in racial/ethnic composition between the AS and immediate treatment groups. In our AS cohort, 79 (42.0%) experienced clinical reclassification and underwent deferred treatment. BCR rates were similar between treatment groups. Race/ethnicity were not found to be predictors of clinical reclassification, while metrics at diagnostic biopsy such as elevated PSA, higher PSA density, and lower prostate volume increased reclassification odds.

CONCLUSIONS

In our diverse population, NHB race and Hispanic ethnicity were not significant predictors of adverse reclassification while on AS. Our findings support utilizing other metrics taken at initial biopsy to identify high-risk patients such as PSA, prostate volume, and PSA density.

Increasing aggressive prostate cancer

INTRODUCTION

To compare prostate biopsy (Pbx) characteristics, before and after the 2012 United States Preventive Services Task Force (USPSTF) prostate cancer screening guidelines in our practice.

MATERIALS AND METHODS

We completed a retrospective comparative analysis of 1703 sequential patients that had a Pbx in 2010 to 2012 (3 years) with 1006 patients biopsied in 2018, 2019 and 2021 (3 years). Data from a total of 2709 Pbx was collected on patient age, race, prostate-specific antigen (PSA), digital rectal examination (DRE) and Gleason sum score (GSS). The data was analyzed to determine whether the 2012 USPSTF screening recommendations against prostate cancer screening may have affected prostate cancer characteristics. Two study groups were defined as Group A and Group B. Group A represents Pbx prior to the 2012 USPSTF screening guidelines (2010-2012) and Group B represents Pbx in 2018-19 and 2021. The patient population consisted of 76% Black, 14% White and 11% other.

RESULTS

The number of patients that had a Pbx in Groups A vs. B: 567 patients/year vs. 335 patients/year. The annual positive Pbx rate for Group A vs. B: 134/year vs. 175/year. High grade prostate cancer (GSS 7-10) in Groups A vs. B: 51.5% vs. 59%. The proportion of patients with a PSA 10 ng/mL or greater in Groups A vs. B: 25.4% vs. 31%. The PSA 10 ng/mL and over and GSS 7-10 was higher in Group B for all age groups. In 2021, GSS 7-10 was present in 64% of 70-80 year olds. In Group B, GSS 6 decreased by 7.5% while GSS 7-10 increased by 7.5% compared with Group A.

CONCLUSIONS

Our data through the year 2021 shows that after the 2012 USPSTF recommendations against prostate cancer screening, Pbx decreased and prostate cancer diagnosis and high grade (GSS 7-10) prostate cancer increased. As our patient population consists of 76% Black patients and 33% of men age 70-80 years old, our results support annual prostate cancer screening for US men 50-80 years old and especially high-risk patients that include Black men, men with a family history of prostate cancer and healthy men age 70-80 years old. Annual DRE- and PSA- based prostate cancer screening will likely markedly decrease prostate cancer morbidity, mortality and the cost of prostate cancer management.

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.

Confirmatory transperineal saturation prostate biopsy combined with mpMRI decrease the reclassification rate in men enrolled in Active Surveillance: Our experience in 100 men submitted to eight-years scheduled biopsy

Introduction: The reclassification rate for clinically significant prostate cancer (csPCa) in men enrolled in Active Surveillance (AS) as been prospective-ly evaluated. Patients and methods: One hundred patients with very low risk PCa underwent after 8 years a scheduled transperineal prostate biopsy (SPBx = 20 cores) combined with additionalmpMRI/TRUS fusion biopsies (4 cores) of lesions PI-RADS scores ≥ 3. All the patients, after initial diagnosis, previously had mpMRI evaluation combined with transperineal saturation prostate biopsy (confirmatory and 3-year scheduled biopsy). Risk reclassification at repeat biopsy triggering the recommen-dation for active treatment was defined as over 3 or more than 10% of positive cores, Gleason score > 6/ISUP Grade Group ≥ 2, greatest percentage of cancer (GPC) > 50%.Results: Multiparametric MRI was suspicious (PI-RADS ≥ 3) in 30 of 100 cases (30.0%); 70 (70.0%) vs. 20 (20.0%) vs. 10(10.0%) patients had a PI-RADS score ≤ 2 vs. 3 vs. 4, respec-tively. Two (2.0%) patients with PI-RADS score 3 and 4 were upgraded (ISUP Grade Group 2); SPBx and MRI/TRUS fusion biopsy diagnosed 100% and 0% of csPCa, respectively. Conclusions: Transperineal SPBx combined with mpMRI at ini-tial confirmatory biopsy allow to select an high number of men at very low risk of reclassification during the AS follow up (2.0%of the cases at 8 years from diagnosis); these data could be use-ful to reduce the number of scheduled repeated prostate biopsy during the AS follow up.

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.

Genetic Factors Associated with Prostate Cancer Conversion from Active Surveillance to Treatment

Men diagnosed with low-risk prostate cancer (PC) are increasingly electing active surveillance (AS) as their initial management strategy. While this may reduce the side effects of treatment for prostate cancer, many men on AS eventually convert to active treatment. PC is one of the most heritable cancers, and genetic factors that predispose to aggressive tumors may help distinguish men who are more likely to discontinue AS. To investigate this, we undertook a multi-institutional genome-wide association study (GWAS) of 5,222 PC patients and 1,139 other patients from replication cohorts, all of whom initially elected AS and were followed over time for the potential outcome of conversion from AS to active treatment. In the GWAS we detected 18 variants associated with conversion, 15 of which were not previously associated with PC risk. With a transcriptome-wide association study (TWAS), we found two genes associated with conversion (MAST3, p = 6.9×10-7 and GAB2, p = 2.0×10-6). Moreover, increasing values of a previously validated 269-variant genetic risk score (GRS) for PC was positively associated with conversion (e.g., comparing the highest to the two middle deciles gave a hazard ratio [HR] = 1.13; 95% Confidence Interval [CI]= 0.94-1.36); whereas, decreasing values of a 36-variant GRS for prostate-specific antigen (PSA) levels were positively associated with conversion (e.g., comparing the lowest to the two middle deciles gave a HR = 1.25; 95% CI, 1.04-1.50). These results suggest that germline genetics may help inform and individualize the decision of AS-or the intensity of monitoring on AS-versus treatment for the initial management of patients with low-risk PC.