There has long been a question about the potential role of active surveillance as a management strategy for men diagnosed with prostate cancer and with a Gleason score of 3 + 4 = 7.
Clearly, active surveillance is not going to be a wise strategy for men with high-volume Gleason 7 disease, a long life expectancy, and a PSA >10 ng/ml. However, there is a very real question about whether active surveillance may be appropriate for men with only small amounts of localized Gleason 3 + 4 disease. A new report by Park et al. addresses precisely these patients.
The research team conducted a retrospective review of data from 907 patients who had had a radical prostatectomy for treatment of localized prostate cancer at the Cancer Institute of New Jersey during the past 5 years. Their goal was to try to identify just how many of these patients, diagnosed with Gleason 3 + 4 disease at biopsy, may have been appropriate candiddates for active surveillance as opposed to immediate surgical treatment.
Here is what they found:
- Out of the 907 men in the Center’s database, 66 had been diagnosed with low-volume prostate cancer and a Gleason score of 3 + 4 = 7 at biopsy were identified.
Among these 66 patients:
- The overall rate of upgrading (to a higher Gleason score) after surgery was 31.8 percent.
- The overall rate of upstaging was 25.6 percent.
- Preoperative PSA levels were significantly higher in patients who were upgraded (p = 0.015).
- The optimal preoperative PSA cutoff level for the prediction of upgrading was 4.73 ng/ml.
- Men with a maximum of < 15% of their biopsy cores positive for cancer had a significantly lower upstaging rate than those with >15 percent of their biopsy cores positive (p = 0.035).
- Statistically, the patients’ clinical stage (p = 0.061) and number of positive cores (p = 0.081) were only marginally associated with upgrading and upstaging.
Park et al. conclude that, for men with low-volume, localized prostate cancer and a Gleason score of 3 + 4 on biopsy, under-estimation of risk for upgrading and upstaging “may be effectively avoided when we select patients with PSA < 4.73 and … maximum cancer involvement on positive cores < 15 percent.” In other words, such patients may be appropriate candidates for initial management using active surveillance.