Is active surveillance reasonable for some men with Gleason 7 prostate cancer?

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.

8 Responses

  1. I love the logic. But when it is “you” that has cancer with Gleason score of 7 … why is it that most patients choose not to “risk” and roll the dice?

    I agree that the key words are “initial management using active surveillance” … but how many urologist/patient relationships can monitor and sustain active surveillance in a timely way with a Gleason score of 7? In some areas of the country, prostate cancer patients must wait weeks to even get appointments with their urologists … so how active should “active” surveillance be?

  2. Change is hard. For everyone. If you think about it, however, certain aspects of “active” surveillance (like regular PSA tests) can easily be arranged with your primary care physician, with test results also being provided to the urologist.

  3. It’s bullshit to expect the medical system to maintain an effective active surveillance program. Each individual has to take that burden on himself and monitor his own cancer. I do it, and so should the rest of you sheep who depend upon the “system” to take care of you. Your problem is you have insurance, so your brains are on vacation.

  4. Dear Mr. Simpson:

    I am sorry but: (1) there is no need to be rude and (2) even you cannot manage some aspects of a reliable active surveillance program for yourself (e.g., writing prescriptions for PSA tests and MRIs, let alone conducting your own repeat biopsies should these be necessary).

  5. Hey, Fred. Just because you are capable of monitoring your own cancer, doesn’t mean everyone else can. I can attest, first hand, the difficulties of getting a timely appointment, even though I had cancer. How do you think I felt as my PSA kept creeping up?

    So Joe Public gets a PSA tests monthly and it goes up from 4.1 to 4.2 in a month. Does that mean the patient should go back to the doctor? How about the guy whose PSA only goes up to 1.2? Is he capable of decided his situation without advice? This is all about a “team” of doctor and patient with a concerted plan for AS, as this web site touts.

    By your post, Fred, it looks like you just have a boner (pun intended) for the US medical system and are pretty frustrated. And although it is easy to call out the patients to be accountable, the only path to success involves collaborative decisions by all of the stakeholders.

  6. This article now applies to me. I have been on AS for a year, and my annual biopsy came back good and bad. Positive cores were down to 2/12 (from 3/12), with an equal or lesser percentage of tumor. So, that’s the good. The bad is that the Gleason score notched up to a 7 (from a 6). It’s 3 + 4 (not 4 + 3, thank God).

    We are sending my pathology slides for a second opinion today. My urologist says that, if it’s a confirmed 7, he wants me to get treated. If it’s back to a 6, he said “See you in a year”. Wish me luck!

  7. Just thought I would share with you folk, as I can thank God for modern medicine.

    My husband recently went through his cancer journey. He has always had yearly PSA checks and, at the age of 68, his PSA went from 1 to 8.7 ng/ml in less than 12 months. He was treated first for a possible infection; then he was given a biopsy, with the worst possible result! Gleason score 5 + 5: a very aggressive high density cancer! Only 2 years ago, here where we live in South Australia, they would only have been able to treat him with hormones. Thankfully, he was reasonably fit after two hip replacements — due to playing golf, and swimming daily.

    His team of specialists decided to try this plan:

    — 6 months of hormone treatment (injections)
    — Fiducial markers (gold seeds) implanted after 3 months, then
    — 5 weeks of daily external beam radiotherapy (40 Gy)
    — 2 weeks of rest and then overnight stay in hospital for a 5-hour high-dose brachytherapy procedure during which 12 needles were inserted around his prostate and he was given 80 Gy of radiation therapy.

    The process took 8 months in total!!

    Scans showed no activity in his bones, etc., and now his PSA is less than 0.05 ng/ml and the cancer appears to have been contained. Naturally there will be all the follow-up visits over the next few years, but we are eternally grateful that here in South Australia, we have access to a good local GP, and top class specialists. We do also have private health coverage. But, gentlemen, you personally have to be vigilant and aware of any significant change in body function and act accordingly. This may mean having more regular PSA checks (by your request!).

    If my husband had not been concerned about his “flow” problem, it would have been too late! And sometimes, if the doctor just says, “Come back in a year,” don’t be too accepting, as my husband’s PSA results went up like this: May 2011, 1; Jan 2012, 4.1; Jun 2012, 6.7; Jul 2012, 7.1; Aug 2012, 8.4 ng/ml.

    Thank you for allowing me a little of your time, and I do hope this has been of interest. If it helps one man to ask questions that could be life saving, then I thank the Lord for giving me the wisdom to share.

    Just remember, your journey is your own and no two treatments will be the same, but God bless you as you face the uncertainty, and trials ahead.

  8. Thanks for the thoughtful reply! Glad to hear of your outcome!


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