EAU 2017: Active Surveillance for 3+4=7 Prostate Cancer - Pro

London, England (UroToday.com) In this session, Dr. Cooperberg argued in favor of including select Gleason 3+4=7 prostate cancer patients in active surveillance programs. Prostate cancer is the most commonly diagnosed cancer and ranks third in cancer causes of death among men in the United States. Since the 2012 United States Preventive Services Task Force (USPSTF) recommendations against prostate cancer screening in all men, a marked decline has been noted in prostate cancer incidence. In fact, it now approximates levels last seen in the 1980s prior to widespread adoption of PSA screening. The USPSTF recommendation was in response to overdiagnosis and overtreatment. Yet, the reduced incidence remains concerning given the lack of an appropriate substitution for PSA and concomitant reduction in diagnosis of both low and high risk prostate cancers.

The urologic community has countered criticisms of overtreatment by increasing active surveillance (AS) rates among low risk patients, which are employed in nearly half of patients as recently as 2013. Some have advocated for including select intermediate risk patients in modern AS protocols. In the UCSF cohort, there appears to be little difference in progression-free survival for intermediate risk compared to low risk patients as stratified by the CAPRA risk score. Although there is some concern from a recent report out of Toronto regarding increase cancer-specific mortality in intermediate risk patients, Dr. Cooperberg argued that our selection process needs to become more nuanced for these patients. He highlighted that even expert pathologists have a hard time distinguishing between Gleason 3+3=6 and 3+4=7 on controversial cases (rate of agreement was approximately 27%). Grade concordance is expected to be even lower in the community. This has significant implications for patient management since most 3+3 would be targeted for AS protocols while treatment would be recommended for 3+4. Moreover, not all 3+4 is created equally. Recent publications identifying the quantitative Gleason score (Reese et al., Cancer 2012; 118:6046) and IQ Gleason (Sauter et al. Eur Urol 2016;69:592) demonstrate clear differences in outcome when percentage of pattern 4 and tertiary pattern 5 are considered. Lastly, the NCCN guidelines suggest that AS can be considered for select patients with low volume pattern 4 and/or age > 75.

In conclusion, Dr. Cooperberg contends that AS should clearly be an option for select men with 3+4 disease. He identified a challenge are for how we should be defining progression in these tumors and believes that answers may be found in next generation imaging and molecular analysis. He closed with the comment that “if we do not fix overtreatment, we cannot defend screening.”
Hopkins cohort 5 deaths

Speaker(s): M. Cooperberg, San Francisco, CA, USA

Written By: Benjamin T. Ristau, MD, SUO Fellow, Fox Chase Cancer Center, Philadelphia, PA

at the #EAU17 - March 24-28, 2017- London, England