THE "NEW" PROSTATE CANCER INFOLINK

A group in the UK has published data on the outcomes of a large, contemporary cohort of patients with low-risk prostate cancer who met the UK National Institute for Health and Clinical Excellence guidelines for management with active surveillance but who were in fact treated with laparoscopic radical prostatectomy (LRP) in a single surgeon series.

Louie-Johnsun et al. report on data from 1,080 consecutive patients who underwent LRP between March 2000 and April 2008. Of these patients, 549/1,080 (51 percent) had preoperative low risk disease (PSA  < 10 ng/ml, clinical stage ≤ T2a, and biopsy Gleason score ≤ 6) and a subgroup of 74/549 patients were assessed preoperatively as having “insignificant’” disease.

The results of the analysis are as follows:

• The mean age of the patients was 61 years
• The mean PSA level was 6.1 ng/ml (range 1 to 9 ng/ml)
• 38 percent of patients were preoperatively staged as cT2a.
• 126/549 patients (23 percent) were upgraded on final pathology to Gleason score ≥ 7.
• 29/549 patients (5 percent) had extraprostatic extension — with seminal vesicle invasion in 5 patients (0.9 percent).
• Of the 74 patients with preoperative prediction of insignificant disease, 45 (61 percent) had significant disease and 12 (16 percent) were upgraded to an intermediate-risk group.
• Positive margins were evident in 44/549 patients (8.0 percent).
• Biochemical failure occurred in 6/549 patients (1.1 percent) with a median follow-up of 28 months.

The authors conclude that, in this contemporary UK cohort of patients with apparently low- or favorable-risk prostate cancer, nearly a quarter (23% percent) will have higher grade disease than predicted prior to surgery. They further conclude that, “Even though active surveillance is increasingly being recommended for managing low-risk localized prostate cancer, patients and their physicians need to be aware of the potential for harboring more significant disease.”

These data seem to bear out similar data published in the USA in the past couple of years, and emphasize the need for better biomarkers that will allow us to differentiate between the patients with truly indolent prostate cancer and those with a notable probability for progressive disease. Of course what this paper still does not help us to resolve is the question of what percentage of the 549 low-risk patients could have been adequately managed with active surveillance. One has to assume that this might have been the case for a significant proportion of these patients.