Active surveillance; a reasonable management alternative for patients with prostate cancer: the Miami experience

Has Active Surveillance for Prostate Cancer Become Safer? Lessons Learned from a Global Clinical Registry

BACKGROUND AND OBJECTIVE

Active surveillance (AS) has evolved into a widely applied treatment strategy for many men around the world with low-risk prostate cancer (or in selected cases intermediate-risk disease). Here, we report on the safety and acceptability of AS, and treatment outcomes for low- and intermediate-risk tumours over time in 14 623 men with follow-up of over 6 yr.

METHODS

Clinical data from 26 999 men on AS from 25 cohorts in 15 countries have been collected in an international database from 2000 onwards.

KEY FINDINGS AND LIMITATIONS

Across our predefined four time periods of 4 yr each (covering the period 2000-2016), there was no significant change in overall survival (OS). However, metastasis-free survival (MFS) rates have improved since the second period and were excellent (>99%). Treatment-free survival rates for earlier periods showed a slightly more rapid shift to radical treatment. Over time, there was a constant proportion of 5% of men for whom anxiety was registered as the reason for treatment alteration. There was, however, also a subset of 10-15% in whom treatment was changed, for which no apparent reason was available. In a subset of men (10-15%), tumour progression was the trigger for treatment. In men who opted for radical treatment, surgery was the most common treatment modality. In those men who underwent radical treatment, 90% were free from biochemical recurrence at 5 yr after treatment.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our study confirms that AS was a safe management option over the full duration in this large multicentre cohort with long-term follow-up, given the 84.1% OS and 99.4% MFS at 10 yr. The probability of treatment at 10 yr was 20% in men with initial low-risk tumours and 31% in men with intermediate-risk tumours. New diagnostic modalities may improve the acceptability of follow-up using individual risk assessments, while safely broadening the use of AS in higher-risk tumours.

PATIENT SUMMARY

Active surveillance (AS) has evolved into a widely applied treatment strategy for many men with prostate cancer around the world. In this report, we show the long-term safety of following AS for men with low- and intermediate-risk prostate cancer. Our study confirms AS as a safe management option for low- and intermediate-risk prostate cancer. New diagnostic modalities may improve the acceptability of follow-up using individual risk assessments, while safely broadening the use of AS in higher-risk tumours.

Advances in the selection of patients with prostate cancer for active surveillance

Early identification and management of prostate cancer completely changed with the discovery of prostate-specific antigen. However, improved detection has also led to overdiagnosis and consequently overtreatment of patients with low-risk disease. Strategies for the management of patients using active surveillance - the monitoring of clinically insignificant disease until intervention is warranted - were developed in response to this issue. The success of this approach is critically dependent on the accurate selection of patients who are predicted to be at the lowest risk of prostate cancer mortality. The Epstein criteria for clinically insignificant prostate cancer were first published in 1994 and have been repeatedly validated for risk-stratification and selection for active surveillance over the past few decades. Current active surveillance programmes use modified criteria with 30-50% of patients receiving treatment at 10 years. Nonetheless, tools for prostate cancer diagnosis have continued to evolve with improvements in biopsy format and targeting, advances in imaging technologies such as multiparametric MRI, and the identification of serum-, tissue- and urine-based biomarkers. These advances have the potential to further improve the identification of men with low-risk disease who can be appropriately managed using active surveillance.

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.

Clinical experience with active surveillance protocol using regular magnetic resonance imaging instead of regular repeat biopsy for monitoring: A study at a high-volume center in Korea

Background

Here, we report the experience of a multiparameter magnetic resonance imaging (MRI)–based active surveillance (AS) protocol that did not include performing a repeat biopsy after the diagnosis of prostate cancer by prostate biopsy or transurethral resection of prostate.

Methods

From January 2010 to December 2017, we reviewed 193 patients with newly diagnosed prostate cancer who were eligible for AS. The patients were divided into AS group (n = 122) and definitive treatment group (n = 71) based on initial treatment. Disease progression was defined as a remarkable change in MRI findings. To confirm the stability of protocol, we compared the clinicopathological characteristics of patients who initially underwent radical prostatectomy (RP) (n = 58) and RP after termination of AS (n = 20).

Results

Among patients who initially selected AS (median adherence duration = 31.4 months), 70 (57.3%) subsequently changed their treatment options. Disease progression (n = 30) was the main cause for termination. No significant differences were found in the clinicopathologic characteristics at initial diagnosis and pathologic outcomes between patients who initially underwent RP and those who chose RP after termination of AS. In a comparative analysis of diagnostic methods, the patients with incidental prostate cancer by transurethral resection of prostate had higher age, lower prostate-specific antigen level and density, as well as longer AS adherence duration and follow-up duration compared with those diagnosed by prostate biopsy.

Conclusions

Our AS monitoring protocol, which depends on MRI instead of regular repeat biopsy, was feasible. Patients with incidental prostate cancer continued AS more compared with patients diagnosed by prostate biopsy.

Association Between African American Race and Clinical Outcomes in Men Treated for Low-Risk Prostate Cancer With Active Surveillance

Importance

There is concern that African American men with low-risk prostate cancer may harbor more aggressive disease than non-Hispanic White men. Therefore, it is unclear whether active surveillance is a safe option for African American men.

Objective

To compare clinical outcomes of African American and non-Hispanic White men with low-risk prostate cancer managed with active surveillance.

Design, Setting, and Participants

Retrospective cohort study in the US Veterans Health Administration Health Care System of African American and non-Hispanic White men diagnosed with low-risk prostate cancer between January 1, 2001, and December 31, 2015, and managed with active surveillance. The date of final follow-up was March 31, 2020.

Exposures

Active surveillance was defined as no definitive treatment within the first year of diagnosis and at least 1 additional surveillance biopsy.

Main Outcomes and Measures

Progression to at least intermediate-risk, definitive treatment, metastasis, prostate cancer-specific mortality, and all-cause mortality.

Results

The cohort included 8726 men, including 2280 African American men (26.1%) (median age, 63.2 years) and 6446 non-Hispanic White men (73.9%) (median age, 65.5 years), and the median follow-up was 7.6 years (interquartile range, 5.7-9.9; range, 0.2-19.2). Among African American men and non-Hispanic White men, respectively, the 10-year cumulative incidence of disease progression was 59.9% vs 48.3% (difference, 11.6% [95% CI, 9.2% to 13.9%); P < .001); of receipt of definitive treatment, 54.8% vs 41.4% (difference, 13.4% [95% CI, 11.0% to 15.7%]; P < .001); of metastasis, 1.5% vs 1.4% (difference, 0.1% [95% CI, -0.4% to 0.6%]; P = .49); of prostate cancer-specific mortality, 1.1% vs 1.0% (difference, 0.1% [95% CI, -0.4% to 0.6%]; P = .82); and of all-cause mortality, 22.4% vs 23.5% (difference, 1.1% [95% CI, -0.9% to 3.1%]; P = 0.09).

Conclusions and Relevance

In this retrospective cohort study of men with low-risk prostate cancer followed up for a median of 7.6 years, African American men, compared with non-Hispanic White men, had a statistically significant increased 10-year cumulative incidence of disease progression and definitive treatment, but not metastasis or prostate cancer-specific mortality. Longer-term follow-up is needed to better assess the mortality risk.

Comparing Perspectives of Canadian Men Diagnosed With Prostate Cancer and Health Care Professionals About Active Surveillance

Active surveillance (AS) has gained acceptance as a primary management approach for patients diagnosed with low-risk prostate cancer (PC). In this qualitative study, we compared perspectives between patients and health care professionals (HCP) to identify what may contribute to patient-provider discordance, influence patient decision-making, and interfere with the uptake of AS. We performed a systematic comparison of perspectives about AS reported from focus groups with men eligible for AS (7 groups, N = 52) and HCP (5 groups, N = 48) who engaged in conversations about AS with patient. We used conventional content analysis to scrutinize separately focus group transcripts and reached a consensus on similar or divergent viewpoints between them. Patients and clinicians agreed that AS was appropriate for low grade PC and understood the low-risk nature of the disease. They shared the perspective that disease status was a critical factor to pursue or discontinue AS. However, men expressed a greater emphasis on quality of life in their decisions related to AS. Patients and clinicians differed in their perspectives on the clarity, availability, and volume of information needed and offered; clinicians acknowledged variations between HCP when presenting AS, while patients were often compelled to seek additional information beyond what was provided by physicians and experienced difficulty in finding or interpreting information applicable to their situation. A greater understanding of discordant perspectives about AS between patients and HCP can help improve patient engagement and education, inform development of knowledge-based tools or aids for decision-making, and identify areas that require standardization across the clinical practice.

How to Pick Out the "Unreal" Gleason 3 + 3 Patients: A Nomogram for More Precise Active Surveillance Protocol in Low-Risk Prostate Cancer in a Chinese Population

OBJECTIVE

To develop a nomogram for selecting the "unreal" Gleason score (GS) 3 + 3 patients in biopsy GS 3 + 3 prostate cancer (PCa) patients.

METHODS

Patients who were newly diagnosed with PCa by biopsy and underwent radical prostatectomy in the First Affiliated Hospital of Nanjing Medical University from January 2009 to October 2018 were enrolled. Comparisons were made between GS 3 + 3 and higher grade PCa patients. Logistic regression analysis was performed to determine the risk factors for the "unreal" GS 3 + 3 PCa in biopsy GS 3 + 3 patients. Then, a nomogram was developed to predict the probability of "unreal" GS 3 + 3 PCa according to the results of multivariate analysis. Finally, receiver operating characteristic and decision curve analysis (DCA) curves were structured to identify the efficiency of the predictive model.

RESULTS

Compared to higher GS grade, biopsy GS 3 + 3 had greater upgrade risk (P < 0.05) while a lower proportion of positive surgical margins, seminal vesicle invasion, extra-prostatic extension, lymph node invasion, and nerve invasion (all P < 0.05). Multivariate analysis showed that age, PSAD, prostate imaging reporting and data system (PI-RADS) score and biopsy positive cores were significant risk factors for "unreal" GS 3 + 3. A nomogram was developed utilizing these factors with high prediction performance (area under curve = 0.924). Furthermore, DCA curve suggested that this predictive model was effective.

CONCLUSIONS

The nomogram identified the probability of "unreal" GS 3 + 3 PCa in biopsy GS 3 + 3 PCa patients, which was of great value for clinical guidance in low risk PCa therapy.

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.

A decision analysis comparing 3 active surveillance protocols for the treatment of patients with low-risk prostate cancer

BACKGROUND

Active surveillance (AS) is a viable management option for approximately 50% of men who are newly diagnosed with prostate cancer. To the authors' knowledge, no direct comparisons between the different variants of AS protocols have been conducted to date. The authors developed a microsimulation decision model to evaluate which of 3 alternative AS protocols is optimal for men with low-risk prostate cancer, and compared each of these with immediate treatment.

METHODS

Men who were diagnosed with low-risk prostate cancer at age 65 years were modeled as having been treated with either immediate therapy or via each of 3 AS protocols. Modeled AS protocols represent those in the literature; a modified AS protocol was included in a sensitivity analysis. Immediate therapy included radical prostatectomy, external-beam radiotherapy, or brachytherapy. Outcome measures were quality-adjusted life-years (QALYs) and costs. Cost-effectiveness analysis and deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Immediate therapy produced fewer QALYs than all variants of AS. Of the AS protocols evaluated, biennial biopsy was found to be the only efficient option, with an incremental cost-effectiveness ratio of $3490 per QALY compared with immediate therapy. It delayed the need for curative therapy by a mean of 56 months, and was found to be preferred in >86.9% of cases in probabilistic sensitivity analysis. A modified version of low-intensity AS dominated all other options.

CONCLUSIONS

For a 65-year-old man with low-risk prostate cancer, AS with biennial biopsy appears to be highly cost-effective compared with common alternatives. An AS protocol using triennial biopsy was found to dominate all other strategies and should be considered for men who are comfortable with a longer period between biopsies. The optimal strategy depends on a patient's tolerance for periodic biopsies and comfort with delaying radical treatment. Physicians should incorporate these patient preferences into decision making.

Green tea extract for prevention of prostate cancer progression in patients on active surveillance

Background

Active surveillance (AS) has evolved as a management strategy for men with low grade prostate cancer (PCa). However, these patients report anxiety, doubts about the possible progression of the disease as well as higher decisional conflict regarding selection of active surveillance, and have been reported to ultimately opt for treatment without any major change in tumor characteristics. Currently, there is a paucity of research that systematically examines alternate strategies for this target population.

Methods

We conducted a review the evidence from epidemiological, in vitro, preclinical and early phase trials that have evaluated green tea catechins (GTC) for secondary chemoprevention of prostate cancer, focused on men opting for active surveillanceof low grade PCa.

Results

Results of our review of the in vitro, preclinical and phase I-II trials, demonstrates that green tea catechins (GTC) can modulate several relevant intermediate biological intermediate endpoint biomarkers implicated in prostate carcinogenesis as well as clinical progression of PCa, without major side effects.

Discussion

Although clinical trials using GTC have been evaluated in early phase trials in men diagnosed with High-Grade Prostatic Intraepithelial Neoplasia, Atypical Small Acinar Proliferation and in men with localized disease before prostatectomy, the effect of GTC on biological and clinical biomarkers implicated in prostate cancer progression have not been evaluated in this patient population.

Conclusion

Results of these studies promise to provide a strategy for secondary chemoprevention, reduce morbidities due to overtreatment and improve quality of life in men diagnosed with low-grade PCa.

Contemporary approach to active surveillance for favorable risk prostate cancer

The approach to favorable risk prostate cancer known as “active surveillance” was first described explicitly in 2002. This was a report of 250 patients managed with a strategy of expectant management, with serial prostate-specific antigen and periodic biopsy, and radical intervention advised for patients who were re-classified as higher risk. This was initiated as a prospective clinical trial, complete with informed consent, beginning in 2007. Thus, there are now 20 years of experience with this approach, which has become widely adopted around the world. In this chapter, we will summarize the biological basis for active surveillance, review the experience to date of the Toronto and Hopkins groups which have reported 15-year outcomes, describe the current approach to active surveillance in patients with Gleason score 3 + 3 or selected patients with Gleason score 3 + 4 with a low percentage of Gleason pattern 4 who may also be candidates, enhanced by the use of magnetic resonance imaging, and forecast future directions.

Low-risk prostate cancer selected for active surveillance with negative MRI at entry: can repeat biopsies at 1 year be avoided? A pilot study

PURPOSE

In patients considered for active surveillance (AS), the use of MRI and targeted biopsies (TB) at entry challenges the approach of routine "per protocol" repeat systematic biopsies (SB) at 1 year. This pilot study aimed to assess whether an approach of performing repeat biopsies only if PSA kinetics are abnormal would be safe and sufficient to detect progression.

METHODS

Prospective single-centre study of 149 patients on AS with low-risk PCa, a negative MRI at entry, followed for a minimum of 12 months between 01/2007 and 12/2015. Group 1 (n = 78) patients had per-protocol 12-month repeat SB; group 2 (n = 71) patients did not. Surveillance tests for tumour progression were for both groups: for cause SB and MRI-TB biopsies if PSA velocity (PSA-V) > 0.75 ng/ml/year, or PSA doubling time (PSADT) < 3 years. The main objectives are to compare the 2-year rates of tumour progression and AS discontinuation between groups. The secondary objectives are to estimate the diagnostic power of PSA-V and PSA-DT, to predict the risk of tumour progression.

RESULTS

Overall, 21 out of 149 patients (14.1%) showed tumour progression, 17.1% for group 1 and 12.3% for group 2, and 31 (21.2%) discontinued AS at 2 years. There was no difference between the 2 groups (p = 0.56). The area under the PSA-V and PSADT curves to predict tumour progression was 0.92 and 0.83, respectively.

CONCLUSIONS

We did not find any significant difference for progression and AS discontinuation rate between the 2 groups. The PSA kinetic seems accurate as a marker of tumour progression. These results support the conduct of a multi-centre prospective trial to confirm these findings.

Active surveillance review: contemporary selection criteria, follow-up, compliance and outcomes

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.

Predictors for the detection of prostate cancer and clinically significant prostate cancer using TRUS-guided biopsy in patients with negative initial biopsy results

PURPOSE

We aimed to determine the predictors for the detection of prostate cancer and clinically significant prostate cancer in the setting of repeat prostate biopsy using trans-rectal ultrasonography-guided biopsy.

METHODS

A total of 636 patients who underwent repeat prostate biopsy were included. The patients were divided into two groups according to the repeat biopsy results (with vs. without prostate cancer). A multivariable analysis was performed to assess the predictors for the detection of prostate cancer and clinically significant prostate cancer.

RESULTS

Prostate cancer was detected in 98 patients (15.4%). Although there was no difference in the prostate-specific antigen velocity, the prostate-specific antigen density was higher in the patients with prostate cancer at the initial (0.14 vs. 0.17 ng/mL/cc, p = 0.049) and repeat biopsies (0.17 vs. 0.26 ng/mL/cc, p < 0.001). The proportions of the patients who met the active surveillance criteria were as follows: 22.4% (Johns Hopkins), 30.6% (University of Toronto), 32.7% (University of California at San Francisco), 30.6% (Prostate Cancer Research International Active Surveillance), 27.6% (Memorial Sloan Kettering Cancer Center), and 13.3% (University of Miami). In the multivariable analysis, age, hypoechoic lesion on trans-rectal ultrasonography, and prostate-specific antigen density at the repeat biopsy were the significant predictors for prostate cancer and clinically significant prostate cancer.

CONCLUSIONS

Trans-rectal ultrasonography before repeat prostate biopsy and the prostate-specific antigen density are useful for selecting patients with a high probability for prostate cancer if repeat trans-rectal ultrasonography-guided biopsy is considered. In addition, these are also helpful for detecting clinically significant prostate cancer.

A novel biopsy-related parameter derived from location and relationship of positive cores on standard 12-core trans-rectal ultrasound-guided prostate biopsy: a useful parameter for predicting tumor volume compared to number of positive cores

PURPOSE

To develop a novel biopsy-related parameter, named overlapping line, defined as the line between the adjacent positive cores on 12-core trans-rectal ultrasound-guided prostate biopsy, and evaluated the value of overlapping line for predicting tumor volume in the final pathologic examination.

METHODS

Among patients with prostate cancer who underwent radical prostatectomy at Boramae Medical Center, 470 patients who underwent standard 12-core trans-rectal ultrasound-guided prostate biopsy were selected for the analysis. The number of overlapping line was determined in each patient, and its effects on tumor volume were evaluated after adjusting for other variables.

RESULTS

Median prostate specific antigen level was 9.1 ng/mL, and the maximum % cancer in positive cores was 42.8%. Median numbers of positive cores and overlapping lines were three and two, respectively. The pathologic stage was T2 or less, T3a, and T3b or greater in 297 (63.5%), 104 (22.2%), and 67 patients (14.3%), respectively. Median tumor volume in prostatectomy specimen was 3.4 mL. In multivariable analysis, the number of overlapping lines (B 0.750, p < 0.001) was a significant predictor for tumor volume, in addition to prostate specific antigen level and maximum % cancer in positive cores. In addition, the model with overlapping line showed superior accuracy compared to the model with positive core based adjusted r ² (0.467 vs. 0.456).

CONCLUSIONS

The number of overlapping lines, a novel prostate biopsy-related variable, is thought to be a more reliable predictor for tumor volume compared to the number of positive cores and could be easily applied to routine daily practice.

Low serum testosterone predicts upgrading and upstaging of prostate cancer after radical prostatectomy

Often, pathological Gleason Score (GS) and stage of prostate cancer (PCa) were inconsistent with biopsy GS and clinical stage. However, there were no widely accepted methods predicting upgrading and upstaging PCa. In our study, we investigated the association between serum testosterone and upgrading or upstaging of PCa after radical prostatectomy (RP). We enrolled 167 patients with PCa with biopsy GS ≤6, clinical stage ≤T2c, and prostate-specific antigen (PSA) <10 ng ml⁻¹ from April 2009 to April 2015. Data including age, body mass index, preoperative PSA level, comorbidity, clinical presentation, and preoperative serum total testosterone level were collected. Upgrading occurred in 62 (37.1%) patients, and upstaging occurred in 73 (43.7%) patients. Preoperative testosterone was lower in the upgrading than nonupgrading group (3.72 vs 4.56, P< 0.01). Patients in the upstaging group had lower preoperative testosterone than those in the nonupstaging group (3.84 vs 4.57, P= 0.01). In multivariate logistic regression analysis, as both continuous and categorical variables, low serum testosterone was confirmed to be an independent predictor of pathological upgrading (P = 0.01 and P= 0.01) and upstaging (P = 0.01 and P = 0.02) after RP. We suggest that low serum testosterone (<3 ng ml⁻¹) is associated with a high rate of upgrading and upstaging after RP. It is better for surgeons to ensure close monitoring of PSA levels and imaging examination when selecting non-RP treatment, to be cautious in proceeding with nerve-sparing surgery, and to be enthusiastic in performing extended lymph node dissection when selecting RP treatment for patients with low serum testosterone.

Is there any association between National Institute of Health category IV prostatitis and prostate-specific antigen levels in patients with low-risk localized prostate cancer?

Purpose

We investigated the association between National Institute of Health category IV prostatitis and prostate-specific antigen levels in patients with low-risk localized prostate cancer.

Materials and Methods

The data of 440 patients who had undergone prostate biopsies due to high PSA levels and suspicious digital rectal examination findings were reviewed retrospectively. The patients were divided into two groups based on the presence of accompanying NIH IV prostatitis. The exclusion criteria were as follows: Gleason score>6, PSA level>20ng/mL, >2 positive cores, >50% cancerous tissue per biopsy, urinary tract infection, urological interventions at least 1 week previously (cystoscopy, urethral catheterization, or similar procedure), history of prostate biopsy, and history of androgen or 5-alpha reductase use. All patient's age, total PSA and free PSA levels, ratio of free to total PSA, PSA density and prostate volume were recorded.

Results

In total, 101 patients were included in the study. Histopathological examination revealed only PCa in 78 (77.2%) patients and PCa+NIH IV prostatitis in 23 (22.7%) patients. The median total PSA level was 7.4 (3.5–20.0) ng/mL in the PCa+NIH IV prostatitis group and 6.5 (0.6–20.0) ng/mL in the PCa group (p=0.67). The PSA level was≤10ng/mL in 60 (76.9%) patients in the PCa group and in 16 (69.6%) patients in the PCa+NIH IV prostatitis group (p=0.32).

Conclusions

Our study showed no statistically significant difference in PSA levels between patients with and without NIH IV prostatitis accompanying PCa.

The importance of active surveillance, and immediate re-biopsy in low-risk prostate cancer: The largest series from Turkey

OBJECTIVE

To evaluate long-term outcomes of active surveillance (AS) applied in low-risk prostate cancer patients, and the impact of re-biopsy results on the prediction of progression.

MATERIAL AND METHODS

In our clinic, patients who had undergone AS for low-risk localized prostate cancer between the years 2005-2013 were included in the study. Our AS criteria are Gleason score ≤6, prostate-specific antigen (PSA) level <10 ng/mL, number of positive cores <3, maximum cancer involvement ratio <50% each core. Immediate re-biopsy (within 3 months) was performed to 65 patients who accepted AS. Finally, 43 patients who met re-biopsy criteria were included in the study. Prostate biopsy specimens were harvested from 12 cores under the guidance of transrectal ultrasound (TRUS). Re-biopsy was performed within 3 months (1-12 weeks). In re-biopsy, a total of 20 core biopsies were performed including the far lateral (6 cores) and transition zone (2 cores) in addition to standard 12 core biopsy. Our follow-up protocol is PSA measurement and digital rectal examination (DRE) every 3 months within the first 2 years, than every 6 months. Control biopsies was performed one year later and once upon every 3 years to patients whose PSA levels and DREs were normal at follow-up visits. More than 2 tumor invaded cores or 50% tumor in one core, and Gleason score exceeding 6 points were accepted as indications for definitive treatment. Patients were divided into two groups by re-biopsy results and compared according to the time to progression. We have done multivariate regression analysis to predict prognosis by using data on age, PSA level, and detection of tumor in re-biopsy specimens.

RESULTS

Patients' median age was 61 years and PSA level was 5 (2.7-9) ng/mL. Tumor was detected in 22 (34%) patients at re-biopsy and they underwent definitive treatment. Additionally tumor was detected in 9 patients, but active surveillance was maintained because their pathologic results met active surveillance criteria. Median follow time was 42 (24-117) months. Definitive treatment was performed in 9 (21%) patients. PSA recurrence was not detected in none of 9 patients during 38 months of follow up. Only the presence of tumor in re-biopsy specimens was found predictor of disease progression in multivariate analysis.

CONCLUSION

We think that AS is safe method for low-risk localized prostate cancer patients, if it is performed in compliance with certain criteria and regular follow up, and early re-biopsy can be useful either during early period or long term follow-up.

Active surveillance for prostate cancer: current evidence and contemporary state of practice

Prostate cancer remains one of the most commonly diagnosed malignancies worldwide. Early diagnosis and curative treatment seem to improve survival in men with unfavourable-risk cancers, but significant concerns exist regarding the overdiagnosis and overtreatment of men with lower-risk cancers. To this end, active surveillance (AS) has emerged as a primary management strategy in men with favourable-risk disease, and contemporary data suggest that use of AS has increased worldwide. Although published surveillance cohorts differ by protocol, reported rates of metastatic disease and prostate-cancer-specific mortality are exceedingly low in the intermediate term (5-10 years). Such outcomes seem to be closely associated with programme-specific criteria for selection, monitoring, and intervention, suggesting that AS--like other management strategies--could be individualized based on the level of risk acceptable to patients in light of their personal preferences. Additional data are needed to better establish the risks associated with AS and to identify patient-specific characteristics that could modify prognosis.

Acknowledging unreported problems with active surveillance for prostate cancer: a prospective single-centre observational study

OBJECTIVE

To report outcomes of patients with localised prostate cancer (PCa) managed with active surveillance (AS) in a standard clinical setting.

DESIGN

Single-centre, prospective, observational study.

SETTING

Non-academic, average-size hospital in Switzerland.

PARTICIPANTS

Prospective, observational study at a non-academic, average-size hospital in Switzerland. Inclusion and progression criteria meet general recommendations. 157 patients at a median age of 67 (61-70) years were included from December 1999 to March 2012. Follow-up (FU) ended June 2013.

RESULTS

Median FU was 48 (30-84) months. Overall confirmed reclassification rate was 20% (32/157). 20 men underwent radical prostatectomy with 1 recurrence, 11 had radiation therapy with 2 prostate-specific antigen relapses, and 1 required primary hormone ablation with a fatal outcome. Kaplan-Meier estimates for those remaining in the study showed an overall survival of 92%, cancer-specific survival of 99% and reclassification rate of 41%. Dropout rate was 36% and occurred at a median of 48 (21-81) months after inclusion. 68 (43%) men are still under AS.

CONCLUSIONS

Careful administration of AS can and will yield excellent results in long-term management of PCa, and also helps physicians and patients alike to balance quality of life and mortality. Our data revealed significant dropout from FU. Patient non-compliance can be a relevant problem in AS.

Biomarkers for prostate cancer: present challenges and future opportunities

Prostate cancer (PCa) has variable biological potential with multiple treatment options. A more personalized approach, therefore, is needed to better define men at higher risk of developing PCa, discriminate indolent from aggressive disease and improve risk stratification after treatment by predicting the likelihood of progression. This may improve clinical decision-making regarding management, improve selection for active surveillance protocols and minimize morbidity from treatment. Discovery of new biomarkers associated with prostate carcinogenesis present an opportunity to provide patients with novel genetic signatures to better understand their risk of developing PCa and help forecast their clinical course. In this review, we examine the current literature evaluating biomarkers in PCa. We also address current limitations and present several ideas for future studies.

Analysis of expanded criteria to select candidates for active surveillance of low-risk prostate cancer

We aimed to analyze the value of each criterion for clinically insignificant prostate cancer (PCa) in the selection of men for active surveillance (AS) of low-risk PCa. We identified 532 men who were treated with radical prostatectomy from 2006 to 2013 who met 4 or all 5 of the criteria for clinically insignificant PCa (clinical stage ≤ T1, prostate specific antigen [PSA] density ≤ 0.15, biopsy Gleason score ≤ 6, number of positive biopsy cores ≤ 2, and no core with > 50% involvement) and analyzed their pathologic and biochemical outcomes. Patients who met all 5 criteria for clinically insignificant PCa were designated as group A (n = 172), and those who met 4 of 5 criteria were designated as group B (n = 360). The association of each criterion with adverse pathologic features was assessed via logistic regression analyses. Comparison of group A and B and also logistic regression analyses showed that PSA density > 0.15 ng ml⁻¹ and high (≥7) biopsy Gleason score were associated with adverse pathologic features. Higher (> T1c) clinical stage was not associated with any adverse pathologic features. Although ≤ 3 positive cores were not associated with any adverse pathology, ≥4 positive cores were associated with higher risk of extracapsular extension. Among potential candidates for AS, PSA density > 0.15 ng ml⁻¹ and biopsy Gleason score > 6 pose significantly higher risks of harboring more aggressive disease. The eligibility criteria for AS may be expanded to include men with clinical stage T2 tumor and 3 positive cores.

[Active surveillance of low risk prostate cancer]

In Europe prostate cancer is one of the most common cancers among men. The diagnostics always include a control of the prostate-specific antigen (PSA) level and examination of a representative tissue sample from the prostate. With these findings it is possible to evaluate the degree of progression of the cancer and its prognosis. Several treatment options for localized prostate cancer are given by national and international guidelines including radical prostatectomy, percutaneous radiation therapy, or brachytherapy and surveillance of the cancer with optional treatment at a later stage. For the latter treatment option, known as active surveillance, strict criteria have to be met. The advantage of active surveillance is that only patients with progressive cancer are subjected to radical therapy. Patients with very slow or non-progressing cancer do not have to undergo therapy and thus do not have to suffer from the side effects. The basic idea behind active surveillance is that some cancers will not progress to a stage that requires treatment within the lifetime of the patient and therefore do not require treatment at all. Unfortunately the criteria for active surveillance are not definitive enough at the current time leading only to a delay in effective treatment for many patients. The surveillance strategy has without doubt a high significance among the treatment options for prostate cancer; however, at the current time it lacks reliable indicators for a certain prognosis. Therefore, patients must be informed in detail about the advantages and disadvantages of active surveillance.

Predictive criteria of insignificant prostate cancer: what is the correspondence of linear extent to percentage of cancer in a single core?

Objective

The aim of active surveillance of early prostate cancer is to individualize therapy by selecting for curative treatment only patients with significant cancer. Epstein’s criteria for prediction of clinically insignificant cancer in surgical specimens are widely used. Epstein’s criterion “no single core with >50% cancer” has no correspondence in linear extent. The aim of this study is to find a possible correspondence.

Materials and Methods

From a total of 401 consecutive patients submitted to radical prostatectomy, 17 (4.2%) met criteria for insignificant cancer in the surgical specimen. The clinicopathologic findings in the correspondent biopsies were compared with Epstein’s criteria for insignificant cancer. Cancer in a single core was evaluated in percentage as well as linear extent in mm.

Results

Comparing the clinicopathologic findings with Epstein’s criteria predictive of insignificant cancer, there was 100% concordance for clinical stage T1c, no Gleason pattern 4 or 5, ≤2 cores with cancer, and no single core with >50% cancer. However, only 25% had density ≤0.15. The mean, median and range of the maximum length of cancer in a single core in mm were 1.19, 1, and 0.5-2.5, respectively. Additionally, the mean, median, and range of length of cancer in all cores in mm were 1.47, 1.5, and 0.5-3, respectively.

Conclusion

To pathologists that use Epstein’s criteria predictive of insignificant cancer and measure linear extent in mm, our study favors that “no single core with >50% cancer” may correspond to >2.5 mm in linear extent.

Disease reclassification risk with stringent criteria and frequent monitoring in men with favourable-risk prostate cancer undergoing active surveillance

OBJECTIVES

To determine the frequency of disease reclassification and to identify clinicopathological variables associated with it in patients with favourable-risk prostate cancer undergoing active surveillance (AS).

PATIENTS AND METHODS

We assessed 191 men, selected by what may be the most stringent criteria used in AS studies yet conducted, who were enrolled in a prospective cohort AS trial. Clinicopathological characteristics were analysed in a multivariate Cox proportional hazards regression model. Key features were an extended biopsy with a single core positive for Gleason score (GS) 3 + 3 (<3 mm) or 3 + 4 (<2 mm) and a prostate-specific antigen (PSA) level <4 ng/mL (adjusted for prostate volume). Biopsies were repeated every 1-2 years and clinical evaluations every 6 months. Disease was reclassified when PSA level increased by 30% from baseline, or when biopsy tumour length increased beyond the enrolment criteria, more than one positive core was detected or any grade increased to a dominant 4 pattern or any 5 pattern.

RESULTS

Disease was reclassified in 32 patients (16.8%) including upgrading to GS 4 + 3 in five patients (2.6%). The median (interquartile range) follow-up time among survivors was 3 (1.9-4.6) years. Overall, 13 of the 32 (40.6%) had incremental increases in GS. Tumour length (hazard ratio 2.95, 95% confidence interval [CI] 1.34-6.46; P = 0.007) and older age (hazard ratio 1.05, 95% CI 1.00-1.09; P = 0.05) were identified as significant and marginally significant predictors of disease reclassification, respectively. Disease remained stable in 83.2% of patients.

CONCLUSION

The need persists for improvements in risk stratification and predictive indicators of cancer progression.

Image-based monitoring of targeted biopsy-proven prostate cancer on active surveillance: 11-year experience

PURPOSE

To report our 11-year experience of Active Surveillance (AS) program focusing on modern transrectal ultrasound (TRUS)-based monitoring of targeted biopsy-proven cancer lesion.

METHODS

Consecutive patients on AS, who had targeted biopsy-proven lesion followed by at least a repeat surveillance biopsy and three times TRUS monitoring of the identical visible lesion, were included. Doppler grade of blood flow signal within the lesion was classified from grade 0 to 3. Biopsy-proven progression was defined as upgrade of Gleason score or 25% or greater increase in cancer core involvement.

RESULTS

Fifty patients were included in this study. Clinical variables (median) included age (61 years), clinical stage (T1c, 42;T2, 8), PSA (4.6 ng/ml), and Gleason score (3 + 3, n = 41;3 + 4, n = 9). Of the 50 patients, 34 demonstrated pathological progression at a median follow-up of 4.4 years. In comparing between without (n = 16) and with (n = 34) pathological progression, there were significant differences in cancer core involvement at entry (p = 0.003), the major axis diameter (p = 0.001) and minor axis diameter (p = 0.001) of the visible lesion at entry, increase in the major axis diameter (p = 0.005) and minor axis diameter (p = 0.013), and upgrade of Doppler grade (p < 0.0001). In multivariate analysis for predicting pathological progression, the increase (≥25%) in diameter of biopsy-proven lesion (hazard ratio, 15.314; p = 0.023) and upgrade of Doppler grade (hazard ratio, 37.409; p = 0.019) were significant risk factors.

CONCLUSIONS

Longitudinal monitoring of the TRUS-visible biopsy-proven cancer provides a new opportunity to perform per-lesion-based AS. The increase in diameter and upgrade of Doppler grade of the lesion were significant risk factors for biopsy-proven progression on AS.

Active surveillance and focal therapy for low-intermediate risk prostate cancer

Low risk and many cases of low-intermediate risk prostate cancer, are indolent, have little or no metastatic potential, and are not life threatening. Major advances have been made in understanding who these patients are, and in encouraging the use of conservative management in such individuals. Conservative management incorporates the early identification of those 'low risk' patients who harbor higher risk disease, and benefit from definitive therapy. Based on the current algorithm of PSA followed by systematic biopsy, this represents about 30% of newly diagnosed low risk patients. A further small proportion of patients with low risk disease demonstrate biological progression to higher grade disease. Men with lower risk disease can defer treatment, usually for life. Men with higher risk disease that can be localized to a relatively small volume of the prostate may be candidates for focal, prostate sparing therapy. The results of active surveillance, embodying conservative management with selective delayed intervention for the subset who are re-classified as higher risk over time based on repeat biopsy, imaging, or biomarker results, have shown that this approach is safe in the intermediate to long term, with a 1-5% cancer specific mortality at 15 years. Further refinement of the surveillance approach is ongoing, incorporating MRI, targeted biopsies, and molecular biomarkers.

Characteristics and experiences of patients with localized prostate cancer who left an active surveillance program

BACKGROUND

Understanding the experiences of men leaving active surveillance programs is critical to making such programs viable for men with localized prostate cancer.

OBJECTIVE

To generate hypotheses about the factors that influence patients' decisions to leave an active surveillance program.

METHODS

Using data from the Johns Hopkins active surveillance cohort, bivariate analyses and multinomial regression models examined characteristics of men who self-elected to leave, those who stayed in the program, and those who left because of disease reclassification. We interviewed patients who self-elected to leave.

RESULTS

Of 1,159 men in active surveillance, 9 % self-elected to leave. In interviews with a sample of 14 men who self-elected to leave, uncertainty involved in active surveillance participation, existence of personal criteria-distinct from providers' clinical criteria-and fear of cancer were important factors in decisions to leave.

CONCLUSION

Men leaving active surveillance were motivated by a number of factors, including patient-defined criteria, which might differ from clinical recommendations. To ensure active surveillance participation, it may be important to address cancer-related anxiety and personal criteria underlying patient decisions.

Differences among men on active surveillance for very low-risk prostate cancer detected through population-based versus opportunistic prostate-specific antigen-screening

INTRODUCTION

Very low-risk prostate cancer (PCa) is being increasingly managed by active surveillance (AS). Our aim was to assess the influence of the origin of diagnosis on PCa characteristics and treatment rates among men with very low-risk PCa in our prospective AS cohort.

METHODS

Overall, 191 men with very low-risk PCa fulfilling Epstein-criteria underwent protocol-based AS. These men originated either from the prospective population-based screening program (P-AS) or were diagnosed by opportunistic screening (O-AS).

RESULTS

Overall, n = 86 (45.0%) originated from the P-AS group, whereas n = 105 (55.0%) from the O-AS group. On univariate Cox regression analysis, age (HR 0.96, 95% CI 0.92-1.00; p = 0.05), origin of diagnosis (HR 0.72, 95% CI 0.41-1.28; p = 0.001), number of positive cores (HR 2.15, 95% CI 1.18-3.90; p = 0.01) and maximum core involvement (HR 1.03, 95% CI 0.99-1.05; p = 0.05) were predictors for treatment necessity. On multivariate analysis, age (HR 0.95, 95% CI 0.89-0.99; p = 0.05), number of positive cores (HR 2.07, 95% CI 1.10-3.88; p = 0.02), maximum core involvement (HR 1.03, 95% CI 1.00-1.06; p = 0.04) but not origin of diagnosis were independent predictors for treatment necessity. Four men developed biochemical recurrence (all from O-AS group [p = 0.05]).

CONCLUSION

The origin of PCa diagnosis in men undergoing AS had no influence on disease progression and treatment necessity.

Conditional probability of reclassification in an active surveillance program for prostate cancer

PURPOSE

We evaluated the risk of prostate cancer reclassification by time on active surveillance.

MATERIALS AND METHODS

From 1995 to 2014 we evaluated 557 and 251 men at very low and at low risk, respectively, who were on active surveillance and compliant with prostate biopsies. Our primary study outcome was reclassification to higher risk disease by grade or extent. Freedom from reclassification was estimated using the Kaplan-Meier approach with adjustment for covariates using the Cox proportional hazards model.

RESULTS

Within the first 2 years of surveillance patient survival free of reclassification by grade (p = 0.20) and by any biopsy criteria (p = 0.25) was similar in men with very low and low risk disease. After 2 years men with low risk disease were 2.4 times more likely to be diagnosed with a Gleason score of greater than 6 than men with very low risk disease (p = 0.002, HR 2.4, 95% CI 1.9-3.5). Additionally, beyond 2 years on surveillance the risk of lifetime reclassification by grade and by any criteria decreased by 30% and 35% (each p <0.0001, HR 0.70, 95% CI 0.60-0.76 and HR 0.65, 95% CI 0.57-0.72, respectively) with each biopsy that showed no reclassification.

CONCLUSIONS

The reclassification rate during surveillance is not equally distributed across time or risk groups. Due to misclassification at diagnosis the reclassification rate in very low and low risk groups is similar in the first 2 years but differs significantly beyond 2 years. The risk of reclassification decreases with time for each nonreclassifying biopsy beyond 2 years.

Active surveillance for prostate cancer: a systematic review of clinicopathologic variables and biomarkers for risk stratification

CONTEXT

Active surveillance (AS) is an important strategy to reduce prostate cancer overtreatment. However, the optimal criteria for eligibility and predictors of progression while on AS are debated.

OBJECTIVE

To review primary data on markers, genetic factors, and risk stratification for patient selection and predictors of progression during AS.

EVIDENCE ACQUISITION

Electronic searches were conducted in PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to April 2014 for original articles on biomarkers and risk stratification for AS.

EVIDENCE SYNTHESIS

Patient factors associated with AS outcomes in some studies include age, race, and family history. Multiple studies provide consistent evidence that a lower percentage of free prostate-specific antigen (PSA), a higher Prostate Health Index (PHI), a higher PSA density (PSAD), and greater biopsy core involvement at baseline predict a greater risk of progression. During follow-up, serial measurements of PHI and PSAD, as well as repeat biopsy results, predict later biopsy progression. While some studies have suggested a univariate relationship between urinary prostate cancer antigen 3 (PCA3) and transmembrane protease, serine 2-v-ets avian erythroblastosis virus E26 oncogene homolog gene fusion (TMPRSS2:ERG) with adverse biopsy features, these markers have not been consistently shown to independently predict AS outcomes. No conclusive data support the use of genetic tests in AS. Limitations of these studies include heterogeneous definitions of progression and limited follow-up.

CONCLUSIONS

There is a growing body of literature on patient characteristics, biopsy features, and biomarkers with potential utility in AS. More data are needed on practical applications such as combining these tests into multivariable clinical algorithms and long-term outcomes to further improve AS in the future.

PATIENT SUMMARY

Several PSA-based tests (free PSA, PHI, PSAD) and the extent of cancer on biopsy can help to stratify the risk of progression during active surveillance. Investigation of several other markers is under way.

The importance of perceived stress management skills for patients with prostate cancer in active surveillance

Little is known about whether and how stress management skills may improve adjustment for men diagnosed with prostate cancer who opt for active surveillance. This study examined whether two types of perceived stress management skills, specifically the ability to relax and confidence in coping, moderated the relationship between prostate cancer (PC) concerns and psychological distress. Participants were 71 ethnically diverse men in active surveillance. Coping confidence moderated the relationship between PC concerns and intrusive thoughts (p < .01). At low levels of coping confidence, PC concerns was positively related to intrusive thoughts, β = .95, p < .001, but not when coping confidence was high, β = .19, p > .05. Coping confidence also moderated the relationship between PC treatment concerns (a subscale of PC concerns) and intrusive thoughts. At low levels of coping confidence, PC treatment concerns was positively associated with intrusive thoughts, β = .73, p < .001, but not when coping confidence was high, β = .20, p > .05. Findings underscore the importance of interventions aimed at improving coping in men undergoing active surveillance.

Analysis of different tumor volume thresholds of insignificant prostate cancer and their implications for active surveillance patient selection and monitoring

Purpose:

We compared oncological outcomes according to tumor volume (TV) thresholds defining both classical and updated insignificant prostate cancer (IPC), since the TV threshold can be used as clinical parameter for active surveillance.

Methods:

Between 2001 and 2012, we retrospectively analyzed 331 organ-confined prostate cancer patients who had preoperative Gleason score 6, preoperative PSA under 10 ng/mL and pathologic TV less than 1.3 mL. Among them, 81 of 331 (24.5%) had Gleason grade 4/5 disease postoperatively. Patients were stratified into two groups: (1) TV less than 0.5 mL, using the classical definition; and (2) TV between 0.5 mL and 1.3 mL, using the range of updated definition. We compared biochemical recurrence (BCR)-free survival and identified independent predictors of BCR in each group.

Results:

Group 2 had more Gleason grade 4/5 disease than group 1 (P<0.001). On multivariate analysis, Gleason grade 4/5 disease was not associated with BCR in group 1 (P=0.132). However, it was an independent predictor for BCR in group 2 (P=0.042). BCR-free survival were not significantly different according to the presence of Gleason grade 4/5 disease in group 1 (P=0.115). However, in group 2, it was significantly different according to the presence of Gleason grade 4/5 disease (P=0.041).

Conclusions:

Although the TV thresholds of the two definitions of IPC vary only slightly, this difference was enough to result in different clinical course if Gleason grade 4/5 disease was present. Therefore, the updated IPC TV threshold should be carefully applied as clinical parameter for active surveillance.

Initial experience with electronic tracking of specific tumor sites in men undergoing active surveillance of prostate cancer

OBJECTIVES

Targeted biopsy, using magnetic resonance (MR)-ultrasound (US) fusion, may allow tracking of specific cancer sites in the prostate. We aimed to evaluate the initial use of the technique to follow tumor sites in men on active surveillance of prostate cancer.

METHODS AND MATERIALS

A total of 53 men with prostate cancer (all T1c category) underwent rebiopsy of 74 positive biopsy sites, which were tracked and targeted using the Artemis MR-US fusion device (Eigen, Grass Valley, CA) from March 2010 through January 2013. The initial biopsy included 12 cores from a standard template (mapped by software) and directed biopsies from regions of interest seen on MR imaging (MRI). In the repeat biopsy, samples were taken from sites containing cancer at the initial biopsy. Outcomes of interest at second MR-US biopsy included (a) presence of any cancer and (b) presence of clinically significant cancer.

RESULTS

All cancers on initial biopsy had either Gleason score 3+3 = 6 (n = 63) or 3+4 = 7 (n = 11). At initial biopsy, 23 cancers were within an MRI target, and 51 were found on systematic biopsy. Cancer detection rate on repeat biopsy (29/74, 39%) was independent of Gleason score on initial biopsy (P = not significant) but directly related to initial cancer core length (P<0.02). Repeat sampling of cancerous sites within MRI targets was more likely to show cancer than resampling of tumorous systematic sites (61% vs. 29%, P = 0.005). When initial cancer core length was≥4 mm within an MRI target, more than 80% (5/6) of follow-up tracking biopsies were positive. An increase of Gleason score was uncommon (9/74, 12%).

CONCLUSIONS

Monitoring of specific prostate cancer-containing sites may be achieved in some men using an electronic tracking system. The chances of finding tumor on repeat specific-site sampling was directly related to the length of tumor in the initial biopsy core and presence of tumor within an MRI target; upgrading of Gleason score was uncommon. Further research is required to evaluate the potential utility of site-specific biopsy tracking for patients with prostate cancer on active surveillance.

Management of low risk prostate cancer-active surveillance and focal therapy

Low-risk prostate cancer, defined as Gleason Score 6 or less with PSA <10 ng/ml, is diagnosed in about half of men undergoing screening. Approximately 30% of men diagnosed with low-risk disease harbour high-grade cancer that is unrepresented on the biopsy. Moreover, a small percentage of low-grade cancers have molecular alterations that result in progression to aggressive disease. Favourable-risk prostate cancer should be managed with close follow up. Active surveillance is appropriate for most patients with low-risk disease, and radical treatment should be reserved for cases in which higher-risk disease is identified. In turn, focal therapy aims to preserve tissue and function in men who have been diagnosed with localized disease, and should be offered to men with higher risk disease at baseline, as an alternative to whole-gland radiation or surgery, or when the patient transitions from low-risk to higher-risk disease. The two strategies should be viewed as complementary elements of care that can be applied in a risk-stratified manner. In this Review, we discuss the rationale and current status of active surveillance-which constitutes a standard of care in most evidence-based guidelines-and comment on whether and when focal therapy should complement it in those men wishing to continue a tissue-preserving strategy.

The role of magnetic resonance imaging in delineating clinically significant prostate cancer

OBJECTIVE

To determine whether multiparametric magnetic resonance imaging might improve the identification of patients with higher risk disease at diagnosis and thereby reduce the incidence of undergrading or understaging.

METHODS

We retrospectively reviewed the clinical records of 115 patients who underwent multiparametric magnetic resonance imaging before radical prostatectomy. We used Epstein's criteria of insignificant disease with and without a magnetic resonance imaging (MRI) parameter (apparent diffusion coefficient) to calculate sensitivity, specificity, as well as negative and positive predictive values [NPV and PPV] across varying definitions of clinically significant cancer based on Gleason grade and tumor volume (0.2 mL, 0.5 mL, and 1.3 mL) on whole-mount prostate specimens. Logistic regression analysis was performed to determine the incremental benefit of MRI in delineating significant cancer.

RESULTS

The majority had a prostate-specific antigen from 4.1-10.0 (67%), normal rectal examinations (90%), biopsy Gleason score ≤ 6 (68%), and ≤ 2 cores positive (55%). Of the 58 patients pathologically staged with Gleason 7 or pT3 disease at prostatectomy, Epstein's criteria alone missed 12 patients (sensitivity of 79% and NPV of 68%). Addition of apparent diffusion coefficient improved the sensitivity and NPV for predicting significant disease at prostatectomy to 93% and 84%, respectively. MRI improved detection of large Gleason 6 (≥ 1.3 mL, P = .006) or Gleason ≥ 7 lesions of any size (P <.001).

CONCLUSION

Integration of MRI with existing clinical staging criteria helps identify patients with significant cancer. Clinicians should consider utilizing MRI in the decision-making process.

Early experience with active surveillance in low-risk prostate cancer treated

Purpose

This study was conducted to describe our early experience with active surveillance (AS).

Materials and Methods

Between January 2008 and December 2012, 35 patients were treated with AS. Selection criteria included the following: Gleason score ≤6 with single positive core, clinical stage ≤T1c, prostate-specific antigen (PSA) ≤10 ng/mL, and unremarkable imaging results. On patient follow-up, we regularly measured PSA (every 3-6 months) and performed prostate biopsies (after 1 and 3 years).

Results

In the first year of follow-up, prostate biopsies were performed in 25 patients (13 patients, negative for cancer; 7 patients, Gleason score of 6 without progression; 5 patients, progression, treated with radical prostatectomy [RP]). In the third year of follow-up, prostate biopsies were performed in five patients (two patients, negative for cancer; one patient, Gleason score of 6 without progression; two patients, progression, treated with RP). Seven patients discontinued AS because of increased anxiety, and three patients were lost to follow-up. Overall, seven patients (28%) who experienced progression had a mean PSA doubling time (DT) of 7.54 years. Six patients had a PSA DT of more than 3 years, whereas one had a PSA DT of less than 3 years. This study was limited by its small sample size and short follow-up period.

Conclusions

PSA kinetics did not correlate with progression, which suggests that regular biopsies should still be performed. AS is an available treatment option for patients with a low risk of prostate cancer but should only be used in carefully selected patients.

Prostate specific antigen velocity risk count predicts biopsy reclassification for men with very low risk prostate cancer

PURPOSE

Prostate specific antigen velocity is an unreliable predictor of adverse pathology findings in patients on active surveillance for low risk prostate cancer. However, to our knowledge a new concept called prostate specific antigen velocity risk count, recently validated in a screening cohort, has not been investigated in an active surveillance cohort.

MATERIALS AND METHODS

We evaluated a cohort of men from 1995 to 2012 with prostate cancer on active surveillance. They had stage T1c disease, prostate specific antigen density less than 0.15 ng/ml, Gleason score 6 or less, 2 or fewer biopsy cores and 50% or less involvement of any core with cancer. The men were observed by semiannual prostate specific antigen measurements, digital rectal examinations and an annual surveillance biopsy. Treatment was recommended for biopsy reclassification. Patients with 30 months or greater of followup and 3 serial prostate specific antigen velocity measurements were used in primary analysis by logistic regression, Cox proportional hazards, Kaplan-Meier analysis and performance parameters, including the AUC of the ROC curve.

RESULTS

Primary analysis included 275 of 668 men who met very low risk inclusion criteria, of whom 83 (30.2%) were reclassified at a median of 57.1 months. Reclassification risk increased with risk count, that is a risk count of 3 (HR 4.63, 95% CI 1.54-13.87) and 2 (HR 3.73, 95% CI 1.75-7.97) compared to zero. Results were similar for Gleason score reclassification (HR 7.45, 95% CI 1.60-34.71 and 3.96, 95% CI 1.35-11.62, respectively). On secondary analysis the negative predictive value (risk count 1 or less) was 91.5% for reclassification in the next year. Adding the prostate specific antigen velocity risk count improved the AUC in a model including baseline prostate specific antigen density (0.7423 vs 0.6818, p = 0.025) and it outperformed the addition of overall prostate specific antigen velocity (0.7423 vs 0.6960, p = 0.037).

CONCLUSIONS

Prostate specific antigen velocity risk count may be useful for monitoring patients on active surveillance and decreasing the frequency of biopsies needed in the long term.

Divorcing diagnosis from treatment: contemporary management of low-risk prostate cancer

Today, the majority of men with newly diagnosed prostate cancer will present with low-risk features of the disease. Because prostate cancer often takes an insidious course, it is debated whether the majority of these men require radical treatment and the accompanying derangement of quality of life domains imposed by surgery, radiation, and hormonal therapy. Investigators have identified various selection criteria for "insignificant disease," or that which can be monitored for disease progression while safely delaying radical treatment. In addition to the ideal definition of low risk, a lack of randomized trials comparing the various options for treatment in this group of men poses a great challenge for urologists. Early outcomes from active surveillance cohorts support its use in carefully selected men with low-risk disease features, but frequent monitoring is required. Patient selection and disease monitoring methods will require refinement that will likely be accomplished through the increased use of biomarkers and specialized imaging techniques.

Active surveillance: the Canadian experience with an "inclusive approach"

Active surveillance has evolved to become a standard of care for favorable-risk prostate cancer. This is a summary of the rationale, method, and results of active surveillance beginning in 1995 with the first prospective trial of this approach. This was a prospective, single-arm cohort study. Patients were managed with an initial expectant approach. Definitive intervention was offered to those patients with a prostate-specific antigen (PSA) doubling time of less than 3 years, Gleason score progression (to 4+3 or greater), or unequivocal clinical progression. Survival analysis and Cox proportional hazard model were applied to the data. Since November 1995, 450 patients have been managed with active surveillance. The cohort included men under 70 with favorable-risk disease and men of age more than 70 with favorable- or intermediate-risk cancer (Gleason score 3+4 or PSA 10-15). Median follow-up is 6.8 years (range 1-16 years). Overall survival is 78.6%. Ten-year prostate cancer actuarial survival is 97.2%. Five of 450 patients (1.1%) have died of prostate cancer. Thirty percent of patients have been reclassified as higher-risk patients and offered definitive therapy. The commonest indication for treatment was a PSA doubling time less than 3 years (48%) or Gleason upgrading (26%). Of 117 patients treated radically, the PSA failure rate was 50%. This represents 13% of the total cohort. Most PSA failures occurred early; at 2 years, 44% of the treated patients had PSA failure. The hazard ratio for non-prostate cancer mortality to prostate cancer mortality was 18.6 at 10 years. In conclusion, we observed a very low rate of prostate cancer mortality in an intermediate time frame. Among the one-third of patients who were reclassified as higher risk and retreated, PSA failure was relatively common. However, other-cause mortality accounted for almost all of the deaths. Further studies are warranted to improve the identification of patients who harbor more aggressive disease in spite of favorable clinical parameters at diagnosis [reproduced from Klotz (1) with permission from Wolters Kluwer Health].

Quality of life in men undergoing active surveillance for localized prostate cancer

Active surveillance is an important arrow in the quiver of physicians advising men with prostate cancer. Quality-of-life considerations are paramount for patient-centered decision making. Although the overall deleterious impact on health is less dramatic than for those who pursue curative treatment, men on active surveillance also suffer sexual dysfunction and distress. Five-year outcomes revealed more erectile dysfunction (80% vs 45%) and urinary leakage (49% vs 21%) but less urinary obstruction (28% vs 44%) in men undergoing prostatectomy. Bowel function, anxiety, depression, well-being, and overall health-related quality of life (HRQOL) were similar after 5 years, but at 6-8 years, other domains of HRQOL, such as anxiety and depression, deteriorated significantly for those who chose watchful waiting. Further research is needed to compare prospectively HRQOL outcomes in men choosing active surveillance and those never diagnosed with prostate cancer, in part to help weigh the potential benefits and harms of prostate cancer screening.

Preoperative predictors of pathologic stage T2a and pathologic Gleason score ≤ 6 in men with clinical low-risk prostate cancer treated with radical prostatectomy: reference for active surveillance

To assess preoperative parameters that may be predictive of pathologic stage T2a (pT2a) and pathologic Gleason score (pGS) ≤ 6 disease in low-risk prostate cancer patients considering active surveillance. A cohort of 1,495 men with low-risk prostate cancer between 1993 and 2009 was utilized. Preoperative assessment focused on patient age, race, diagnostic PSA level, clinical stage, diagnostic biopsy Gleason score, and prostate cancer laterality. Kaplan-Meier curves and a Cox regression model were used for analysis of PSA recurrence. Preoperative parameters were analyzed by univariate and multivariate logistic regression methods. Of 1,495 patients, 187 (12.5 %) were identified with pT2a and pGS ≤ 6 disease. Of the 187 men with pT2a and pGS ≤ 6 disease, only 6 (3.2 %) cases had PSA recurrence. Kaplan-Meier PSA recurrence-free survival curves identified a difference between prostate cancers with pT2a and pGS ≤ 6 and prostate cancers with >pT2a or pGS ≥ 7 disease (p = 0.002). Only biopsy tumor unilaterality (OR, 10.452; p ≤ 0.001) and low diagnostic PSA levels (OR, 0.887; p = 0.003) were independent predictors of prostate cancers with pT2a and pGS ≤ 6 disease on univariate and multivariate logistic regression. Biopsy tumor unilaterality and low diagnostic PSA levels are the independent predictors of pT2a and pGS ≤ 6 disease in low-risk prostate cancer patients. Unilateral cancer by prostate biopsy and low diagnostic PSA level may be the reference to improving the selection of appropriate candidates for active surveillance within a low-risk prostate cancer cohort.

Active surveillance for favorable-risk prostate cancer: background, patient selection, triggers for intervention, and outcomes

With the advent of increasingly sensitive and widely used diagnostic testing, cancer overdiagnosis in particular has emerged as a problem in multiple organ sites. This has the greatest ramifications in the case of prostate cancer because of the very high incidence of latent prostate cancer in aging men, the availability of the prostate-specific antigen (PSA) test, and the long-term effects of definitive therapy. The condition of most men with favorable-risk prostate cancer is far removed from the consequences of a rampaging, aggressive disease. Most of these men are not destined to die of their disease, even in the absence of treatment. Unfortunately, most of these patients are treated radically and are exposed to the risk of significant side effects. Therefore, a selective approach to treatment is appealing. The concept is to identify the subset that harbor more aggressive disease early enough that curative therapy is still a possibility, thereby allowing the others to enjoy improved quality of life, free from the side effects of treatment. This review article summarizes the evidence supporting active surveillance, and the current approach to this management strategy, including the roles of serial biopsy, PSA kinetics, and MR imaging.

Impact of race on survival in patients with clinically nonmetastatic prostate cancer who deferred primary treatment

BACKGROUND

Prostate cancer (PCa) racial disparity studies typically focus on survival differences after curative treatment. The authors of this report hypothesized that comparing mortality rates between African American (AA) and Caucasian American (CA) patients who deferred primary treatment for clinically nonmetastatic PCa may provide a better assessment of the impact of race on the natural course of PCa.

METHODS

The pathology database of the New York Veterans Administration Medical Center (VAMC), an equal access-of-care facility, was searched for patients with biopsy-proven PCa. Inclusion criteria included 1) no evidence of metastatic disease or death within 3 years after diagnosis, 2) no primary treatment, and 3) a minimum of 5 years of follow-up for survivors.

RESULTS

In total, 518 patients met inclusion criteria between 1990 and 2005. AA patients were younger (P = .02) and had higher median prostate-specific antigen (PSA) levels (P = .001) at the time of diagnosis compared with CA patients. In a multivariate model, higher Gleason score and PSA level were associated with increased mortality (P = .001 and P = .03, respectively), but race was not a predictor of death from PCa.

CONCLUSIONS

The current data suggested that race did not have a major impact on survival in patients with PCa who deferred primary treatment for clinically nonmetastatic disease.

ESUR prostate MR guidelines 2012

The aim was to develop clinical guidelines for multi-parametric MRI of the prostate by a group of prostate MRI experts from the European Society of Urogenital Radiology (ESUR), based on literature evidence and consensus expert opinion. True evidence-based guidelines could not be formulated, but a compromise, reflected by “minimal” and “optimal” requirements has been made. The scope of these ESUR guidelines is to promulgate high quality MRI in acquisition and evaluation with the correct indications for prostate cancer across the whole of Europe and eventually outside Europe. The guidelines for the optimal technique and three protocols for “detection”, “staging” and “node and bone” are presented. The use of endorectal coil vs. pelvic phased array coil and 1.5 vs. 3 T is discussed. Clinical indications and a PI-RADS classification for structured reporting are presented.

Key Points

• This report provides guidelines for magnetic resonance imaging (MRI) in prostate cancer.

• Clinical indications, and minimal and optimal imaging acquisition protocols are provided.

• A structured reporting system (PI-RADS) is described.

Impact of immediate TRUS rebiopsy in a patient cohort considering active surveillance for favorable risk prostate cancer

INTRODUCTION AND OBJECTIVE

Active surveillance (AS) is an option for the management of favorable risk prostate cancer (CaP) in the PSA era. Published studies have reported variable inclusion criteria for cohort selection. Accurate assessment of individual patient risk in AS is dependent not only upon rigorous selection criteria, but also reliability of diagnosis at tissue biopsy. To date, the impact of immediate transrectal ultrasound (TRUS) rebiopsy in confirming candidates for AS has been incompletely defined.

METHODS

From a total of over 567 men, 67 met criteria for AS (Gleason <7, PSA <10, PSAD <0.15, <3 cores with <50% involvement of any 1 core). Fifty-two men agreed to a 12-core TRUS rebiopsy within 6 months of first diagnosis performed in clinic. Statistical analysis was performed using Wilcoxon signed rank test and logistic regression to determine predictors of rebiopsy characteristics, histopathologic outcomes, and impact on treatment choice.

RESULTS

Mean cohort age was 63.9 years (range 56-72 years), PSA 5.9 ng/ml (4.1-10), and PSA density 0.12 ng/ml/cc at initial biopsy. Tumor involved 1.1 cores and 3.2% (range 1%-5%) of the total tissue. Average time to rebiopsy was 2.7 months. Notably, 29 of 52 men (56%) demonstrated no evidence of CaP on repeat biopsy; 14 of 23 men with a positive repeat biopsy showed either an increase in cancer volume (2.8% mean increase) and 9 (18%) were upgraded to Gleason pattern 3+4 = 7. Rebiopsy demonstrated 9 (17%) patients exceeded AS criteria. Nine patients chose curative surgical intervention (radical prostatectomy) based on increased cancer volume or grade (4) or an elective desire for treatment (5). All had organ confined disease with negative margins on final pathologic analysis. Statistical review revealed that initial Gleason score, PSA density, and number of positive cores at first biopsy were not predictive of men with higher volume/grade on re-biopsy.

CONCLUSIONS

Immediate TRUS repeat biopsy after diagnosis frequently fails to redemonstrate prostate cancer confirming the favorable-risk nature of disease burden in this group being considered for AS. A subset of patients are upgraded (17%) leading to reconsideration of AS. We conclude this clinic-based approach provides valuable additional information to discriminate appropriate AS candidates.

Active surveillance for prostate cancer: patient selection and management

Screening for prostate cancer using prostate-specific antigen (PSA) has been appealing. However, the significant associated decline in prostate cancer mortality comes at the cost of a very high rate of diagnosis, and many patients with indolent, non-life-threatening cancer are exposed to the risk of significant side effects from radical treatment. Most men with favourable-risk prostate cancer are not destined to die of their disease, even in the absence of treatment. The challenge is to identify the subset that harbour more aggressive disease early enough that curative therapy is still a possibility, thereby allowing the others to enjoy improved quality of life, free from the side effects of treatment. This article reviews current research into active surveillance in favourable-risk disease and some of the issues that arise when prostate cancer is monitored rather than being treated immediately.

Active surveillance for low-risk prostate cancer: an update

Active surveillance is now an accepted management strategy for men with low-risk localized prostate cancer, in recognition of the knowledge that the majority of men with such cancers are likely to die from other causes. The most obvious benefit of active surveillance is the reduction of morbidity associated with surgery by delaying or avoiding radical gland therapy. Other advantages include lower overall costs to the health-care system and potentially a better quality of life. These advantages should be balanced against the risks of delayed therapy, the most considerable of which being development of more-aggressive disease. Appropriate selection criteria and the definition of triggers for intervention with radical therapy are critical components of an active surveillance protocol. The ability to accurately identify and cure the men whose cancers will progress using clinical, biopsy and imaging data is yet to be resolved, as is the psychological burden of living with an untreated cancer. The benefit of 5α-reductase inhibitors as secondary chemoprevention in men on active surveillance is a new avenue of research. Focal therapy, which has the similar aim of reducing morbidity while maintaining oncological control, is an emerging competitor for active surveillance. Nevertheless, active surveillance is an appealing management option for selected men with prostate cancer.