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Active surveillance is a viable option for men under 60 years of age with low-risk prostate cancer
Keyan Salari, MD, PhD1, David Kuppermann, MD1, Mark A. Preston, MD, MPH2, Douglas M. Dahl, MD1, Jason A. Efstathiou, MD, DPhil1, Michael L. Blute, MD1, Danny Vesprini, MD3, Andrew Loblaw, MD3, Anthony L. Zietman, MD1, Laurence Klotz, MD3, Adam S. Feldman, MD, MPH1.
1Massachusetts General Hospital, Boston, MA, USA, 2Brigham and Women's Hospital, Boston, MA, USA, 3Sunnybrook Health Sciences Centre, Toronto, ON, Canada.

BACKGROUND: Active surveillance (AS) is increasingly used in managing low-risk and favorable intermediate-risk prostate cancer. While most centers do not have a strict age criterion for AS eligibility, younger men are typically counseled to undergo definitive treatment. However, there is limited data on the outcomes of AS in younger men. Here, we evaluate the role of active surveillance for men under 60 years of age diagnosed with low-risk prostate cancer.
METHODS: We retrospectively reviewed two prospective institutional AS cohorts of men diagnosed with low-risk prostate cancer between 1990-2016 (n = 2152) to identify 432 men who began AS before 60 years of age. Clinical outcomes were analyzed, including repeat biopsy data, progression to treatment, and pathologic staging in those who had surgical treatment. Survival analyses for treatment-free survival, metastasis-free survival, cancer-specific survival, and overall survival were conducted using the Kaplan-Meier method.
RESULTS: At diagnosis, median age was 55 years (IQR 53-57) and median PSA was 4.6 ng/mL (IQR 3.1-5.9), with only 11 of 432 men with PSA ≥10 ng/mL. The vast majority of patients had Gleason ≤6 (97.7%) and clinical stage T1 (91.9%) disease. With a median follow-up of 5.1 years (range: 0.05-21.7; IQR: 3.1-8.4), 84.3% (364/432) had a repeat biopsy with 62.6% (228/364) showing prostate cancer, 24.5% (89/364) benign, 7.7% (28/364) with PIN, and 5.2% (10/364) with atypia. Kaplan-Meier actuarial treatment-free survival was 74.3% at 5 years and 55.4% at 10 years. Of all 432 patients, 131 (30.3%) progressed to treatment for the following reasons: pathologic progression (64.1%), PSA progression (18.3%), patient preference (11.5%), volume progression (3.1%) and other reasons (3.1%). Involvement of >20% of any core on diagnostic biopsy (HR 2.01, 95% CI: 1.14-3.54) and PSA density ≥0.15 (HR 1.94, 95% CI: 1.13-3.32) were significant independent predictors of progression to treatment. Among the 131 treated patients, 62.6% underwent radical prostatectomy, 13.0% underwent high-intensity focal ultrasound therapy, 12.2% underwent external beam radiation and 10.7% had brachytherapy. On pathologic review after surgery, 88.2% (60/68) were pT2, and 11.8% (8/68) pT3. The only significant predictor of pT3 disease among patients who underwent radical prostatectomy was >33% core involvement on diagnostic biopsy (OR 2.38, P = 0.01). Five patients developed metastasis (2 with positive lymph nodes at time of radical prostatectomy, 3 with distant metastasis). Metastasis-free survival was 99.7% and 97.5% at 5 and 10 years, respectively. There were no prostate-cancer specific deaths.
CONCLUSIONS: Active surveillance is a reasonable option for carefully selected men under 60 with low-volume, low-risk prostate cancer. However, patients must be surveyed closely and understand the significant risk of ultimately needing treatment.


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