San Diego, California (UroToday.com): Dr. Laurence Klotz from Toronto critically analyzed the outcomes of the Active Surveillance for low to intermediate risk prostate cancer.
Currently, there is a greater recognition of an overtreatment problem and effect on quality of life with treatment. We also know the nature of occult high grade disease. New biomarkers and multiparametric MRI are also having an impact on Active Surveillance and may allow us to identify those who can be placed on surveillance or treated.
Active Surveillance is a success when it avoids mortality and disease related morbidity while at the same time avoiding QOL side-effects.
We are beginning to realize that the metastatic potential of Gleason Score 3 is about zero. Molecular genetics of GS 3 resembles normal cells with a molecular signature distinct from aggressive cancer cells. The major limitation of current active surveillance strategies relate to pathologic miss of coexistent higher grade cancer. Dr. Klotz then poses the question: “If GS 3 does not metastasize, why does volume of GS 3 matter?” He answers that the high volume is a marker for the presence of higher-grade cancer. Under-staging is a major limitation and hopefully mpMRI may allow us to identify clinically significant cancer.
Current predictors of disease reclassification during active surveillance are increased PSA density, race and % core involvement. In their Toronto series, the 15 year CSS is about 5%. Their protocol for AS currently allows for low volume intermediate prostate cancer. However, recent analysis of data suggest a lower Overall Survival, Cancer Specific Survival, and metastatic free survival with any GS 4 component.
The Hopkins protocol is more restrictive and only allows for Epstein criteria (no Gleason pattern 4). Therefore, the 15 year CSS is low at 0.5%.
About 20% of patients who presents with prostate cancer would qualify for Hopkins protocol versus about 50% in the Toronto protocol. Current paradigm of identification for AS is pathological from biopsy and risk stratification. Imaging may change this and may allow us to more accurately identify those who may benefit from AS.
Dr. Klotz concludes that clear candidates for AS include patients with GS6 with non-extensive disease, non-suspicious MRI, and low PSA density. The grey areas are patients with extensive GS6, GS 6 in men < 50 years and GS 7 with < 10% tumor involvement.
In conclusion, the current protocol that Dr. Klotz adopts is:
- Eligibility: most GS 6, PSA< 15, selected GS 3+4 with low volume (<10%)
- Exceptions: High volume GS 6 in young patients, high psa density.
- Workup: MRI and targeted biopsy is done for all high volume GS 6, high PSA density, and any pattern 4 diseases.
- Follow-up: PSA q 6 months
- Confirmatory biopsy or MRI within 1 year. If MRI negative and low risk, biopsy is optional.
- Repeat MRI/biopsy q 3-5 years until age 80.
Presented By: Laurence H. Klotz, MD
Written By: Mohammed Haseebuddin, MD; Fox Chase Cancer Center, Philadelphia, PA at the 2016 AUA Annual Meeting - May 6 - 10, 2016 – San Diego, California, USA
Follow on Twitter: @DrHaseebuddin