BERKELEY, CA (UroToday.com) - Active surveillance (AS) is an option for a subset of men with low-risk prostate cancer (CaP) who are at minimal risk of disease progression. To avoid undergrading or under appreciation of volume of disease, a confirmatory prostate biopsy is often performed prior to embarking on AS. AS patients are then followed with serial PSA monitoring and repeat prostate biopsies. Dr. Ari Adamy and colleagues at Memorial Sloan-Kettering Cancer Center evaluated PSA and the immediate confirmatory prostate biopsy in 531 patients who met inclusion criteria for AS between 1993 and 2009. They evaluated PSA as a predictor of progression using 2 endpoints, including and excluding PSA greater than 10ng/ml as a progression criterion. After exclusions, 238 patients underwent AS and had sufficient followup data.
Inclusion criteria were PSA <10ng/ml, no Gleason grade 4 or 5, clinical stage T1-T2a, 3 or fewer positive biopsy cores and no biopsy core containing more than 50% cancer. PSA monitoring was performed every 6 months. Biopsy was recommended within the first 12-18 months with a repeat biopsy every 2 to 3 years, or for a change in DRE or PSA increase. An increasing PSA usually prompted a repeat biopsy rather than definitive intervention. Median patient age was 64 years and median time to subsequent biopsy was 4.7 months. Median PSA was 4.1ng/ml. With PSA included in the progression criteria, patients without evidence of cancer on the confirmatory biopsy had a 2-year progression-free probability of 84% vs. 74% in patients with a positive confirmatory biopsy. On multivariate analysis, baseline PSA and cancer on confirmatory biopsy were the only independent predictors of progression. When PSA was excluded from the progression criteria, PSA density, 3 positive cores on confirmatory biopsy and positive confirmatory biopsy were significantly associated with progression on univariate analysis. In multivariate analysis, positive confirmatory biopsy significantly increased the risk of disease progression. At 2 years, patients with a negative confirmatory biopsy had a 94% progression-free probability, compared with 87% in those with a positive confirmatory biopsy.
Adamy A, Yee DS, Matsushita K, Maschino A, Cronin A, Vickers A, Guillonneau B, Scardino PT, Eastham JA
J Urol. 2011 Feb;185(2):477-82
10.1016/j.juro.2010.09.095
PubMed Abstract
PMID: 21167529