ESOU18: Treatment Modalities for Intermediate Risk Prostate Cancer - Active Surveillance

Amsterdam, The Netherlands (UroToday.com) Patients with low risk prostate cancer (PC) are hardly likely to die from their disease. Instead the focus in these men should be on avoiding additional harm. In case of advanced disease, the focus is on prolonging survival with acceptable quality of life. In contrast, treatment choices are more crucial in men with intermediate risk PC (IRPC). The definition of IRPC varies according to each different guidelines, and based on three variables: stage, grade and PSA level (Table 1).  Gleason 7 disease is a highly heterogeneous group and if other tumor characteristics are favorable ( PSA < 10 ng/ml, PSA-Density < 0.15 ng/ml/ml and cT1c) and the patient wishes to be treated conservatively, active Surveillance (AS) as a treatment option should be considered. 

A few studies have included patients with IRPC in an AS program. One of the largest trials is the one performed by Klotz et al. [1] The main outcomes measured were overall survival, disease-specific survival, rate of treatment, and PSA failure rate. Twenty-one percent of the patients had IRPC, and 132 had Gleason score (GS) 3+4 disease. One hundred forty-nine of the patients (15%) died, and 844 were still alive at that time. There were 15 deaths from PC (1.5%); the 10-year and 15-year actuarial cause-specific survival rates were 98.1% and 94.3%, respectively, even with 21% of the patients having IRPC. Data from a register-based cohort study of 76,473 PC cases in the National prostate Cancer register (NPCR) of Sweden treated with non-curative intent showed that the observed mortality of men with IRPC was only slightly greater after 5 years of follow-up [2].

Contemporary Gleason grade 4 PC represents a heterogeneous group of various growth patterns comprising of ill-formed, fused, cribriform and glomeruloid glands. The GS 3+4 cases could be candidates for AS if other clinical characteristics are also favorable. A further classification of the GS 3+4 PCs on the basis of growth patterns results in the identification of a GS 3+4 PC with similar outcomes as those with GS 6 cases, leading them to be considered suitable for AS.

AS1


Speaker: M.J. Monique Roobol, MD Professor Department of Urology Erasmus University, Rotterdam, The Netherlands

Written By:
 Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands

References:

  1. Klotz L, Vesprini D, Sethukavalan P, et al. Long-term follow-up of a large active surveillance cohort of patients with prostate cancer. J Clin Oncol. 2015;33:272-7
  2. Rider JR, Sandin F, Andrén O et al. Long-term outcomes among non-curatively treated men according to prostate cancer risk category in a nationwide, population-based study. Eur Urol. 2013 Jan;63(1):88-96. 
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