Beyond the Abstract - Watchful waiting and active surveillance approach in patients with low risk localized prostatic cancer: An experience of out-patients clinic with 12-year follow-up, by Sergey Kravchick, MD

BERKELEY, CA (UroToday.com) - Currently, the liberal use of PSA screening has doubled the detection rates of prostate cancer (PCa).

The European Randomized Screening Trial had shown that 48 prostatectomies were performed to prevent one death. In our study, we investigated the place of expectant management in the patients with low-risk PCa who were treated in the community out-patient clinics of two medical insurance companies. Several objects were chosen as the end points of our study. First, we assessed the value of current tools for expectant management, such as increase in PSA and PSA doubling time (PSA DT). Second, we tried to unveil the long term consequences of delayed treatment. Third, it appeared interesting to set up the optimal number of re-biopsy sessions for expectant protocols. Finally, we evaluated if concomitant diseases and body mass index (BMI) help to categorize patients who might benefit from expectant approach. For the purpose of the latter task, patients’ comorbidity indices were assessed according to Charlson system (CCI).

Nearly 21% of our patients with strict Epstein criteria showed the features of aggressive PCa and most of them had PSA DT 1–5 years. None of the patients, who underwent RP showed evidence of locally advanced disease and only one patient who underwent radiotherapy had biochemical failure.

In our study, higher Gleason score and more cores with the same Gleason score were discovered in 32% of the patients on Active Surveillance and in 92% of the cases those changes were revealed on the first two sessions of re-biopsies. We also found that pain scores were significantly higher in patients who underwent >3 sessions of biopsies.

Our results showed that 17.8% of patients who were diagnosed with PCa met the Epstein criteria and 81.4% of them chose expectant management. However, 41.7% of these men finally chose an active form of treatment. It is worthwhile to emphasize that only half of them had medical indications for intervention. Anxiety supported by “second opinion” caused them to stop expectant management. In addition, we found that nearly 44% of our patients had final CCI ≥1 and that elevated BMI had a high correlation with final CCI incline. Six of our patients with CCI ≥2 died during follow-up from comorbid diseases. In this context, we would like to encourage urologists to make their treatment approach to the patients with low-risk PCa more balanced.

Several limitations of our study should be presumed. All previous studies dedicated to this issue were based on the experience of referral centers. Our study was performed in the community outpatient clinics, where patients can change urologists every 3 months and obtain “second opinion.” This fact causes a bias in indications for active forms of treatment. We also agree that this study might be considered as “low-volume” and accept this drawback.

 

Written by:
Sergey Kravchick, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Watchful waiting and active surveillance approach in patients with low risk localized prostatic cancer: An experience of out-patients clinic with 12-year follow-up - Abstract

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