Active surveillance in low risk, early stage disease: evidence accumulates

A report has just been published of a multi-center retrospective evaluation of the actuarial rates and predictors of remaining on active surveillance, the incidence of cancer progression, and the pathological findings of delayed radical prostatectomy.

Eggener et al. have analyzed data from a cohort of 262 men treated at four tertiary care institutions who met the following inclusion criteria: age 75 years or younger; PSA level of 10 ng/ml or less; clinical stage T1-T2a; biopsy Gleason sum 6 or less; 3 or fewer positive cores at diagnostic biopsy; repeat biopsy before active surveillance; and no treatment for 6 months following the repeat biopsy.

Active surveillance was initiated immediately following the second biopsy. Actuarial rates of remaining on active surveillance were calculated and univariate Cox regression was used to assess predictors of discontinuing active surveillance.

The authors report the following results:

  • At a median follow-up of 29 months, only 43/262 patients (16.4 percent) had received an active treatment.
  • The 2-year and 5-year probabilities of remaining on active surveillance were 91 and 75 percent, respectively.
  • Patients with cancer on the second biopsy, and a higher number of cancerous cores from the two biopsies combined were more likely to undergo treatment.
  • Age, PSA level, clinical stage, prostate volume, and number of total biopsy cores sampled were not predictive of outcome.
  • Skeletal metastases developed in one patient 38 months after initiation of active surveillance.
  • Of the 43 patients undergoing delayed treatment 41 (95 percent) had shown no evidence of disease progression at a median of 23 months following treatment.

The authors conclude that, at a median follow-up of 29 months, active surveillance appears to be safe and associated with a low risk of systemic progression when applied in the management of carefully selected prostate cancer patients. They note that the occurrence of cancer at restaging biopsy and a higher total number of cancerous cores are associated with a lower likelihood of remaining on active surveillance. Finally, they recommend that a restaging biopsy be strongly considered to finalize eligibility for active surveillance.

The “New” Prostate Cancer InfoLink notes that this study adds to the gradual accumulation of evidence supporting the appropriateness of active surveillance as a management strategy for patients diagnosed with early stage, low risk prostate cancer.

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