AUA 2018: Debate - Should We Offer Active Surveillance for Gleason 7 (3+4) Risk Disease? (PRO)

San Francisco, CA ( Peter Carrol, MD gave a talk on the topic of offering active surveillance (AS) for Gleason 7 (3+4) disease. The “old” risk profiling of patients included only the grade and volume of the disease. However, the “new” contemporary risk profiling includes:

  1. Disease volume
  2. PSA density (PSAD)
  3. Multiparametric MRI (mpMRI) 
  4. MRI:TRUS fusion biopsy
  5.  Genomic Testing
  6. Multivariable risk models. 
PSAD has been shown to be a better predictor of treatment and reclassification than PSA. It is possible to refine the risk profiling using a combination of mpMRI, genomic testing, and fusion biopsy.

Studies have shown that treatment free survival for patients with Gleason grade 3+3 is significantly better than for Gleason grade 3+4. With increasing number of cores with Gleason 3+4 disease, the results are worse (Figure 1), and the risk of recurrence after treatment is significantly higher as well. This has been demonstrated in several different cohorts.

Carrol concluded his talk by defining which patients with intermediate risk disease should be offered AS. These include low volume, low PSAD, with favorable genomic testing and mpMRI results. Patients with high volume disease, high PSAD, unfavorable histology (such as cribriform pattern), and unfavorable genomic testing and mpMRI results should be offered immediate treatment. 

Figure 1 – Major upgrade free survival during active surveillance stratified by Gleason score:
Major upgrade free survival during active surveillance

Presented by: Peter Carrol, MD, MPH, University of California, San Francisco 

Read the Opposing Debate: Should We Offer Active Surveillance for Gleason 7 (3+4) Risk Disease? (CON)

Written by:  Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA