Need for Intervention and Survival in a Cohort of Patients on Active Surveillance for Prostate Cancer
Alice Yu, MD1, Edouard Nicaise, BS1, Timothy Baloda, BS1, Andrew Gusev, BS1, David Kuppermann, MD1, Mark Preston, MD, MPH2, Michael Blute, MD1, Douglas Dahl, MD1, Anthony Zietman, MD1, Adam Feldman, MD, MPH1
1Massachusetts General Hospital, Boston, MA, 2Brigham and Women's Hospital, Boston, MA
Background: Active surveillance has become an accepted management strategy for very low risk, low risk, and select cases of favorable intermediate risk localized prostate cancer. Long term data will be critical to continued understanding of which patients are suitable for this strategy and when patients should transition to treatment. We update and investigate long-term follow up in our active surveillance cohort.
Methods: Under IRB approved protocol, a retrospective cohort study of 1291 men diagnosed with localized prostate cancer was performed at a single tertiary-care center from 1996-2016. In 2008 our group agreed on the following AS guidelines: Gleason ≤ 6 (Gleason 7 in select patients with low volume), ≤3/12 cores positive with ≤20% in each core, and PSA <10. Our follow-up protocol includes: PSA/DRE every 4-6 months x 3 years, then annually. Mandatory confirmatory 12 core biopsy is performed at 12-18 months with subsequent biopsies at the discretion of the treating physician. In 2014 multiparametric MRI and fusion biopsy became integrated into our practice. Survival analyses were conducted using the Kaplan-Meier method.
Results: The study cohort consisted of 1291 men with a median age at diagnosis of 66.8 (IQR, 60.8-71.9 years). Median follow-up was 6.4 years (Range, 0.1-22.1 years). The median PSA at diagnosis was 5.1 ng/mL (IQR, 4.0-6.9 ng/mL) with 91% having a PSA < 10 ng/mL. Overall, 97.2% (1255/1291) of patients were Gleason 6 or lower, and 2.8% (36/1291) were Gleason 7. 92.4% (1193/1291) were stage T1c. At the time of analysis, 1155 (89.5%) men were alive and 136 (10.5%) died. Cancer specific survival was 98.8% at 10 years. Freedom from intervention was 68% at 5 years, 57% at 10 years, and 52% at 15 years. 455 men underwent definitive treatment with radical prostatectomy (41.1%), radiation therapy (47.3%), brachytherapy (11.4%) or focal therapy (0.2%). Reasons for intervention included: 74% pathologic progression, 9% PSA progression, 10% patient preference, 1% DRE progression, 3% radiographic progression and 4% other.
Conclusions: Approximately half of men on AS are treated by 10 years with the most common reason being pathologic progression. Active surveillance appears to remain a safe and established management strategy without a negative impact on the patient’s ultimate care.
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