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Need for Intervention and Survival in a Cohort of Patients on Active Surveillance for Low-risk Prostate Cancer
Mark A. Preston, MD, Jonathan J. Paly, M.D., Robert Carrasquillo, M.D., John J. Coen, M.D., Anthony I. Zietman, M.D., Matthew R. Smith, M.D., Chin-Lee Wu, M.D., W Scott McDougal, M.D., Adam S. Feldman, M.D..
Massachusetts General Hospital, Boston, MA, USA.

BACKGROUND:
The specific indications for intervention and survival in patients on Active Surveillance (AS) have not been adequately defined. The purpose of this study was to define indications for treatment and overall survival in a cohort of 499 patients on AS. In the prostate specific antigen (PSA) screening era, and with the growing concern about the “overtreatment” of prostate cancer, active surveillance (AS) is increasingly used as a primary method of managing low-risk prostate cancer. However, long-term data on need for intervention and survival is limited. Our objective was to determine the need for intervention and disease-specific and overall survival in an AS cohort.
METHODS:
Under IRB approved protocol, a historical cohort study of 499 men diagnosed with localized prostate cancer was performed at a single tertiary-care center between 1997 and 2009. Although AS had been practiced throughout this period, in 2008 our group agreed upon inclusion criteria for AS. These included Gleason ≤ 6, Gleason 7 in select patients with low volume, no more than 3/12 cores positive with ≤20% in each core, and PSA <10. Only men with AS as the initial management option were included in the study. Survival analyses were conducted using the Kaplan-Meier method.
RESULTS:
Median age at diagnosis was 68.3 years and median follow-up was 4.8 years. Median PSA at diagnosis was 5.1 ng/mL (0.4-19.2). 98.2% (490/499) of patients were Gleason 6, 1.8% (9/499) were Gleason 7 and 94.0% (469/499) were stage T1a/c. Freedom from intervention was 77% at 5 years and 63% at 10 years. Of the 123 patients requiring treatment, 57 (46.3%) received radiation, 29 (23.6%) received surgery, 17 (13.8%) received brachytherapy and 20 (16.3%) received primary hormonal therapy. Reasons for intervention included; 45.5% (56/123) pathologic progression, 29.3% (36/123) PSA progression, 12.2% (15/123) patient preference, and 5.7% (7/123) DRE progression. Metastases-free survival was 99% at 5 years and 97% at 10 years. Freedom from salvage androgen deprivation was 99% at 5 years and 91% at 10 years. Cancer-specific survival was 100% at 5 and 10 years. Overall survival was 96% at 5 years and 86% at 10 years.
CONCLUSIONS:
In this series, 63 % of patients remained on AS at 10 years. In those treated, pathologic, PSA or DRE progression initiated treatment in 81%. Active surveillance is a treatment method which spares the majority of properly selected men from intervention, provides adequate time for intervention if required, and has durable cancer-specific and overall survival.


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