EAU 2017: 4th ESO Prostate Cancer Observatory: The Urologist’s Perspective on Active Surveillance
Dr. Joniau started by emphasizing the definition of AS based on the recently released EAU-ESTRO-SIOG guidelines on prostate cancer. This generally includes men that (i) follow a predetermined schedule, with a number of potential assessments including digital rectal exam, PSA, re-biopsy, and mpMRI, (ii) have a life expectancy >10 years, (iii) desire to minimize treatment-related toxicity without compromising survival, and (iv) are low risk patients.1 As Dr. Joniau highlights, it is encouraging that AS rates are increasing based on recent literature.
The much publicized ProtecT trial2 demonstrated that a subset of men in the active monitoring group demonstrated worse disease progression compared to the patients receiving surgery or radiotherapy, with the Kaplan-Meier curve starting to deviate at 2 years and more substantially through 10 years. As Dr. Joniau notes, who are these men and what can we do to identify them? In Dr. Joniau’s opinion, these patients are likely candidates for further testing, specifically mpMRI, the Phi test, 4K score and other tissue biomarkers.
In a very recent publication assessing the value of risk-stratification based on MRI and PSA density for reducing unnecessary biopsies without missing Gleason 4 disease for men on AS, Dr Joniau notes that no Gleason upgrading occurred based on MRI-targeted biopsy or transrectal ultrasound guided biopsy in men with PI-RADS 1-3 lesions and PSA density <0.15.3 In Dr. Joniau’s opinion, these patients can be followed with less frequent biopsies.
In summary, we are entering a dynamic time for AS in patients with low risk prostate cancer. Certainly, with improved radiographic imaging and molecular biology diagnostics, we will achieve our goal of over treating men who are not at substantial risk for disease progression, without missing the patient with underlying aggressive prostate cancer.
1. Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2017;71(4):618-629.
2. Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med 2016;375(15):1415-1424.
3. Alberts AR, Roobol MJ, Drost FH, et al. Risk stratification based on magnetic resonance imaging and prostate-specific antigen density may reduce unnecessary follow-up biopsy procedures in men on active surveillance for low risk prostate cancer. BJU Int 2017 Mar 7 [Epub ahead of print].
Presented by: Steven Joniau, University Hospitals Leuven, Leuven, Belgium
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto
Twitter: @zklaassen_md
at the #EAU17 -March 24-28, 2017- London, England