The authors point out that using a single PSA increase during AS may prompt anxiety and premature conversion to active treatment. PSA doubling time (PSADT) on the other hand would permit more rational decision-making in terms of the need for definitive therapy.

A prospective single arm cohort study was performed between 1995 and 2005. Patients under age 70 years with a PSA less than 10ng/ml and Gleason score 6 or less were eligible for inclusion. Patients over 70 years with a PSA between 11 and 15ng/ml or a Gleason score of 7 (3+4) were eligible if a physician had estimated life expectancy to be 10 years or less. Patients were followed every 3 months for the first 2 years and every 6 months thereafter. Prostate biopsy was performed at 2 years. High-risk patients were defined by PSA kinetics or histological upgrading to Gleason 4+3 or greater on repeat biopsy. These criteria would prompt a shift to active therapy.

By March 2005, 231 men had enrolled in the study with a median age of 71 years. Gleason score was 6 or less in 78% and 84% had a PSA less than 10ng/ml at enrollment. With an average follow-up of 3.4 years, 103 men (44.6%) came off surveillance for treatment and 128 (55.4%) remained on surveillance. Overall survival at 8 years was 84%, and prostate cancer specific survival was 98%. Sixteen patients died from other causes and 2 men died from prostate cancer, although the time course of their death suggests likely metastatic disease at time of enrollment.

A mathematical model was developed and applied to facilitate in the differentiation of low and high risk. Three baseline covariates were associated with PSA evolution; initial PSA, age and Gleason score. The manuscript provides several examples of clinical application of the model to different patient scenarios.

Zhang L, Loblaw A, Klotz

J Urol 176:(4)1392-1398

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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