THE "NEW" PROSTATE CANCER INFOLINK

A recent article from a team at Johns Hopkins provides information about the ability to predict biopsy-based progression among their surveillance cohort of men with low-risk prostate cancer.

The article by Tseng et al. is based on a retrospective analysis of data from 376 patients with a median age of 65.5 years (range, 45.8 to 79.5), all of whom were initially diagnosed with low-risk prostate cancer, accepted active surveillance as a management strategy, and underwent at least one follow-up biopsy after their initial diagnosis.

The criteria for acceptance into the Johns Hopkins active surveillance cohort are stringent. In this study, disease progression was defined as the presence of any of the following at the time of a surveillance biopsy:

• Any amount of Gleason pattern 4 or 5 tissue in any biopsy core
• More than two biopsy cores showing the presence of cancer
• More than 50 percent involvement of cancer in any single biopsy core.

The results of the analysis showed the following:

• 123/376 patients (32.7 percent) had progression at a median of 5.6 years after diagnosis (range, 0.3 to 8.5 years).
• The free PSA level (in percent) and the maximum amount of core involvement (also in percent) at the time of initial diagnosis were associated with subsequent progression.
• The presence of cancer and the PSA density at the time of the first surveillance biopsy were also associated with subsequent progression.

Tseng et al. conclude that, “Clinical variables at diagnosis and at first surveillance biopsy during followup in an active surveillance program can be used to inform men about the likelihood of an unfavorable prostate biopsy” at a later date.

It is clear that we are beginning to be able to define criteria for the appropriate guidance of clinicians and their patients regarding the management of patients on active surveillance protocols over time. However, not all the patients meeting the Johns Hopkins criteria for progression (as outlined above) would necessarily need to immediate treatment. Many factors would need to be taken into account before deciding whether an individual patient was an appropriate candidate for treatment, in just the same way as they would be when he was initially diagnosed. What is his age? What is his life expectancy without treatment and with it? What comorbidities affect this? What is his PSA doubling time?

The younger and the healthier the patient, the more appropriate early treatment would seem to be, given the above definition of progression, but there are also likely to be some patients for whom continued surveillance would be a perfectly reasonable option, with the recognition that one might be seeking to delay treatment until it became absolutely necessary for palliative reasons (if it ever, in fact, did). Just look at the age range of the men in this study. The oldest was 79.5 years of age. Could he be treated if he progressed? Perhaps. Should he be treated if he was one of the patients who progressed? That’s a very different question, and his personal opinion on the subject should count for a lot in this discussion.

It would be wrong to think that progression of disease in every patient who was on active surveillance was necessarily a signal for immediate treatment.

Filed under: Living with Prostate Cancer, Management, Treatment Tagged: | active surveillance, prognosis, progression