Management of incident prostate cancer on active surveillance

Back in the dim and distant past (i.e., the 1980s and the very early 1990s, before PSA testing was widespread) one of the most common ways to find early stage prostate cancer was as an incidental consequence of the conduct of a transurethral resection of the prostate (a “TURP”) to treat symptoms of urinary tract obstruction.

Traditional TURPs are now a lot less common than they used to be because we have found other ways to treat that common urological disorder known as benign prostatic hyperplasia (BPH, an enlarged prostate) using laser surgery and a wide variety of pharmaceuticals. Therefore, it is now far less common to have access to tissue samples from TURPs that may include “incidental” prostate cancer or IPC. Without such tissue samples, diagnosis of IPC based on a pathologist’s report is impossible.

Indeed it is worth remembering that the clinical stages T1a and T1b are exclusively reserved as clinical stages for IPCs found as a consequence of a TURP, and the common stage T1c was introduced as a clinical stage to characterize apparently organ-confined prostate cancer found only because of an elevated PSA level.

But … TURPs and other forms of urologic surgery (like suprapubic prostatectomies for apparent bladder obstruction) do still get carried out. IPCs found as a consequence of such surgeries still occur. They are thought to be generally of low risk. And so the obvious question is, “Can we manage IPCs using active surveillance?”

Herden et al. (a German research group based in Cologne and Berlin) have just published what certainly appears to be the first significant set of data that help us to start to answer this question.

Their study (the HAROW study) is a prospective, multi-center, observational study that collected “real life” data from 3,169 patients treated by 259 German clinicians — mostly office-based urologists — from July 2008 to July 2013. Of these 3,169 patients, 224 (7.2 percent) were initially diagnosed with IPC, and these are the patients we want to focus on.

So here is a summary of the findings presented by Herden et al. on their IPC patients.

  • Of the 224 patients with IPC
    • 104 patients were initially managed on active surveillance
    • 5 patients were excluded from the evaluation because they had been followed for 6 months or less.
    • 99 were initially managed on active surveillance and eligible for evaluation.
    • The other 120 patients all elected to have some form of immediate therapy.
  • Of the 99 evaluable patients on active surveillance
    • Average (mean) age was 68.8 years (range (67.4 to 70.2 years).
    • Average (mean) follow-up was 26.5 months.
    • 85 had a Gleason score of 6 or lower.
    • 9 had a Gleason score of 3 + 4 = 7 or higher.
    • 5 had unknown Gleason scores.
    • 2 died during follow-up (but not from prostate cancer).
    • 25 (25 percent) received at least one repeat biopsy.
    • 16 (16 percent) experienced tumor progression.
  • Among the 16 patients experiencing progression
    • Average (mean) time to progression was 9.7 months.
    • Reduction of the PSA doubling time was observed in 11 men.
    • 5 had a Gleason score of ≥ 7 on repeat biopsy.
    • PSA levels were markedly increased.
  • 7/16 men with progression discontinued active surveillance and elected to have curative therapy.
  • 9/16 men with progression did not elect to have curative therapy (for a variety of reasons)
  • 4/83 patients without progression elected definitive therapy or received it on their doctor’s recommendation.

Through this study, Herden et al. have provided us with a strengthened argument that most men diagnosed with IPC are good candidates for at least initial management on active surveillance. On the other hand, this is still a relatively small series of patients, and they have been followed for only an average of just over 2 years. It will be important to see how many of these men are still on active surveillance 5 and 10 years from now before we have a clear idea of the long-term potential of active surveillance in the management of IPC.

Herden et al. conclude as follows:

  • A majority of (German) urologists are comfortable with using active surveillance as a first-line management strategy for IPC.
  • A minority of IPC patients (16 percent) exhibited disease progression at an average of 26.5 months of follow-up.
  • Only elevated PSA density at initial diagnosis was found to correlate with progression.
  • There was no correlation between progression and any other marker studied (including PSA level, Gleason score, and clinical or pathological stage).

The “New” Prostate Cancer InfoLink considers this to be an important new data set that will help patients and their doctors to recognize what one might have very reasonably expected — that most men diagnosed with IPC will be good candidates for initial management on active surveillance.

Editorial note: The “New” Prostate Cancer InfoLink thanks Dr. Jan Herden for rapidly providing us with a full text copy of the article just published on line in Urologia Internationalis, thus allowing us to look at the details of this study.

2 Responses

  1. How timely!

    I am about to see a patient this afternoon with the exact same issue.

    Thank you!!!

  2. Dr. Kelly: Sometimes the magic works! :O)

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