Objective: To evaluate treatment-free survival and oncologic outcomes in patients with IR PCa managed with AS and to compare with AS outcomes in low-risk (LR) PCa patients.
Evidence acquisition: A literature search was conducted through February 2022 using PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed to identify eligible studies. The coprimary outcomes were treatment-free, metastasis-free, cancer-specific, and overall survival. A subgroup analysis was planned a priori to explore AS outcomes when limiting inclusion to IR patients with a Gleason grade (GG) of ≤2.
Evidence synthesis: A total of 25 studies including 29 673 unselected IR patients met our inclusion criteria. The 10-yr treatment-free, metastasis-free, cancer-specific, and overall survival ranged from 19.4% to 69%, 80.8% to 99%, 88.2% to 99%, and 59.4% to 83.9%, respectively. IR patients had similar treatment-free survival to LR patients (risk ratio [RR] 1.16, 95% confidence interval (CI), 0.99–1.36, p = 0.07), but significantly higher risks of metastasis (RR 5.79, 95% CI, 4.61–7.29, p < 0.001), death from PCa (RR 3.93, 95% CI, 2.93–5.27, p < 0.001), and all-cause death (RR 1.44, 95% CI, 1.11–1.86, p = 0.005). In a subgroup analysis of studies including patients with GG ≤2 only (n = 4), treatment-free survival (RR 1.03, 95% CI, 0.62–1.71, p = 0.91) and metastasis-free survival (RR 2.09, 95% CI, 0.75–5.82, p = 0.16) were similar between LR and IR patients. Treatment-free survival was significantly reduced in subgroups of patients with unfavorable IR disease and increased cancer length on biopsy.
Conclusions: The present systematic review and meta-analysis highlight the need to optimize patient selection for those with IR features. Our findings support limiting the inclusion of IR patients in AS to those with low-volume GG 2 tumor.
Patient summary: Active surveillance is increasingly used in patients with localized, intermediate-risk (IR) prostate cancer. In this population, we have reported higher risks of metastasis and cancer mortality in unselected patients than in patients with low-risk features, underscoring the need to optimize the selection of patients with IR features.
Michael Baboudjian,1-4 Alberto Breda,3 Pawel Rajwa,5,6 Andrea Gallioli,3 Bastien Gondran-Tellier,2 Francesco Sanguedolce,3,12 Paolo Verri,3 Pietro Diana,3 Angelo Territo,3 Cyrille Bastide,1 Daniel E. Spratt,7 Stacy Loeb,8 Jeffrey J. Tosoian,9 Michael S. Leapman,10 Joan Palou,3 Guillaume Ploussard,4,11
- Department of Urology, APHM, North Academic Hospital, Marseille, France
- Department of Urology, APHM, La Conception Hospital, Marseille, France
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Barcelona, Spain
- Department of Urology, La Croix du Sud Hôpital, Quint Fonsegrives, France
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Department of Urology, Medical University of Silesia, Zabrze, Poland
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Urology and Population Health, New York University and Manhattan Veterans Affairs, New York, NY, USA
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
- Department of Urology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
- Department of Medical, Surgical and Experimental Sciences, Université degli Studi di Sassari, Italy