Active Surveillance for Localized Prostate Cancer after Long Term Follow Up
Alex Hennessey, MD, Mary Soyster, BA, Ghali Lemtiri-Chlieh, BS, Benjamin Ristau, MD, Peter Albertsen, MD, MPH
University of Connecticut Health Center, Farmington, CT
Active surveillance (AS) is the standard of care for low-risk prostate cancer as detailed in the EAU, AUA, and NCCN guidelines. The ProtecT trial has shown survival outcomes for low and intermediate risk prostate cancer to be excellent. Various criteria have been used to define men who are candidates for AS protocols, with some more restrictive than others. The purpose of this study was to determine whether men meeting more expansive selection criteria were less likely to remain on surveillance.
Materials and Methods
We retrospectively reviewed men monitored on AS by a single urologist at our institution between January 1990 and August 2018. We stratified men into "strict active surveillance" (SAS) and "non-strict active surveillance" (NSAS) categories. SAS was defined as Gleason 6 or less, PSA <10 ng/mL, 1-2 positive biopsy cores, no core with >50% cancer, and PSA density (PSAD) <0.15 ng/mL/g, based on the NCCN definition of "very low risk" prostate cancer. We analyzed progression to treatment, time to treatment, and overall duration of follow-up.
We identified 155 men who underwent AS at our institution. We excluded men seen as second opinions or followed < 1 year. Of these, 100 men met SAS criteria while 55 did not (NSAS). Mean age at diagnosis was 65.6 years for the SAS group and 68.3 years for the NSAS group. Virtually all men were healthy with a mean Charlson Comorbidity Index of 2.59. Median duration of follow-up was 94 months. Men failed to meet SAS criteria primarily because of PSA >10 (47%). In the SAS and NSAS groups, 32 men (32%) and 25 men (45%) ultimately underwent treatment. The median time to treatment was 46 and 39 months for the SAS group and NSAS group respectively. The median duration of follow-up was 90 months for the SAS group and 97 months for the NSAS group. Gleason upgrading was the most likely reason for progression in the SAS group (59%), while a rising serum PSA (64%) was the most likely reason for progression in the NSAS group (p = 0.006). The most common treatment modality was radical prostatectomy (RP) in the SAS group (66%), while androgen deprivation therapy (ADT) (44%) was the most common in the NSAS group (p = 0.007). External beam radiation therapy was the second most common treatment in the SAS group (25%) and RP was the second most common treatment in the NSAS group (32%).
This analysis suggests that men meeting strict criteria for active surveillance are usually younger and progress to treatment because of a rising Gleason grade, while men undergoing active surveillance with more expansive selection criteria are often older and select hormonal therapy with evidence of disease progression.
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