AUA 2017: Active Surveillance is a Viable Option for Men with Borderline Low-Risk Prostate Cancer

Boston, MA ( Eligibility criteria for active surveillance (AS) for low-risk prostate cancer have been defined differently by multiple series reported in the literature. In clinical practice occasional patients not meeting all criteria, may still prefer AS. Dr. Salari presented an interesting study investigating outcomes in borderline cases.

The authors investigated their institutional database of 990 men on AS between 1997-2014. The institutional criteria used for AS eligibility, included Gleason ≤6, stage ≤cT2a, PSA ≤10 ng/mL, ≤3 of 12 cores positive at diagnosis, and ≤20% of any core involved at diagnosis. For the purpose of this analysis, the authors defined borderline cases for AS as those with one or more of either Gleason score 7, PSA >10, stage cT2a, >33% of cores positive at diagnosis, or >20% of any core involved at diagnosis.

In the entire cohort, mean age at diagnosis was 66.9 years (±7.9) and median PSA 5.1 (IQR 4-6.87). While most patients met all institutional AS criteria, 310 patients (31.3%) met at least one of the borderline AS criteria, with 2.4% of patients having Gleason 7, 7.6% with a PSA >10, 8.0% were cT2a, 3.9% (37/943) had >33% of cores positive at diagnosis, and 18.4% (156/848) had >20% of any core involved. With mean follow-up 4.5 years, survival analysis demonstrated no difference in freedom from treatment (FFT) between patients with Gleason 7 vs. ≤6, >33% vs. ≤33% cores involved, or PSA >10 vs. ≤10. Lower FFT was noted among patients with cT2a vs. ≤cT1c disease (62.0% vs. 70.8%, P=0.04), patients with >20% vs. ≤20% of any core involved (61.5% vs. 71.8%, P=0.009), as well as those with PSA density ≥0.15 vs. <0.15 (61.1% vs. 72.0%, P = 0.0006).

In multivariate analysis, >20% core involvement and PSA density ≥0.15 remained a significant predictors for treatment (P=0.003), adjusting for PSA >10, Gleason >6, >33% cores involved, and stage. Among the 310 borderline AS cases, there were only 6 (1.9%) cases of metastasis and 1 (0.3%) prostate cancer-specific death. No significant statistical and clinical differences were demonstrated between borderline AS patients and standard AS patients in this regard, with the standard AS patients demonstrating 10 (1.5%) cases of metastasis and 2 (0.3%) prostate cancer-specific deaths.

In summary, AS remains a viable option for select patients who are borderline cases not meeting current standard AS criteria. However, patients with higher volume disease and higher PSA density may be more likely to progress to treatment. The long-term clinical outcomes of these patients should continue to be investigated.

Presented By: Keyan Salari, Boston, MA

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA