In addition to clinical factors directing the need for active treatment, patient comfort and acceptability for AS is important. In the online edition of Urology, Dr. Ranko Miocinovic and colleagues from the Cleveland Clinic report on the acceptance and durability of AS in men with low-risk CaP.
Men initially identified as candidates for AS underwent a second, confirmatory prostate biopsy. This typically occurred within a couple of months after the diagnostic biopsy, but in some patients it was as long as one year later. Patients were then evaluated at 6 to 12 month intervals with surveillance prostate biopsies performed at least every 2 years. The only trigger for intervention was a change in tumor grade to Gleason score 7-10. The primary study endpoints were freedom from intervention and freedom from recommended intervention.
Between 2004 and 2009, 202 patients with low-risk CaP were considered. Of these, 84 (43%) underwent immediate definitive therapy and 116 (57%) elected AS. A median of 8 months elapsed between the diagnostic and confirmatory prostate biopsies. From the confirmatory biopsy, 27 men (23%) of the 116 had Gleason pattern 4 identified (n=19) or increased CaP volume (n=8) and were recommended to undergo definitive therapy. However, 5 of the 27 elected to remain on AS. Of the 27 men, 6 were treated with radical prostatectomy with overall excellent pathological findings. At a median followup of 20 months, only 1 of 22 patients who was treated with cryotherapy had biochemical recurrence. The 5 patients who elected to continue AS despite the recommendation for treatment have not yet undergone more prostate biopsies. The 89 men on AS following suitable confirmatory prostate biopsy had a median followup of 33 months. The number of repeat prostate biopsies performed in 49, 32, and 8 patients were 1, 0, and 2 respectively. Sixteen men (18%) have undergone definitive therapy and 10 of these had treatment solely at their elective decision. Eight of the 89 patients met criteria for intervention and 6 proceeded with treatment. Five underwent surgery; one had a positive surgical margin and biochemical recurrence and salvage therapy. The 3-year freedom from intervention was 87% and freedom from recommended intervention was 93%.
Miocinovic R, Jones JS, Pujara AC, Klein EA, Stephenson AJ
Urology. 2011 Apr;77(4):980-4