Active surveillance, now the standard of care for most men with favorable risk prostate cancer, is appealing for selected men with 'favorable' intermediate risk prostate cancer. This is a review of the indications for conservative management in this population, the outcome reported in prospective series, and the use of molecular biomarkers and imaging to identify optimal candidates. Candidates are those are men who are intermediate risk either due to a PSA between 10 and 20, or by virtue of having GG2 with a small percentage of Gleason 4 pattern, and a negative MRI or negative targeted biopsy of a region of interest. Confirmation with a favorable score on a tissue based genetic assay can provide further reassurance. A subset of patients with intermediate risk disease have indolent disease that may benefit from AS; at the same time, some men with intermediate risk disease have an aggressive clinical course that deserve early definitive therapy. This heterogeneity is not adequately captured with traditional histopathologic staging. Clinical, genomic, and radiologic biomarkers are the key to appropriate risk stratification and patient selection. The benefits of AS make it an appealing option for selected men with intermediate risk disease.
BJU international. 2019 Oct 24 [Epub ahead of print]
Laurence Klotz
Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON.