BERKELEY, CA (UroToday.com) - The premise of this study was derived from the recent National Institutes of Health State-of-the-Science conference on the Role of Active Surveillance in the Management of Men with Localized Prostate Cancer. This was a panel of 14 experts from the fields of cancer prevention and control, urology, pathology, epidemiology, genetics, transplantation, bioethics, economics, health services research, shared decision making, health communication, and community engagement. The consensus from this conference was that men with low-risk prostate cancer have a very favorable prognosis and therefore “active surveillance has emerged as a viable option that should be offered to patients with low-risk prostate cancer.” However, given that the majority of patients diagnosed with prostate cancer are over the age of 75 and that many of those men will have enlarged prostate glands, there is a risk that older men may have inadequate portions of their prostate gland assessed and be prematurely placed on active surveillance.[2, 3] We proposed that older men may actually have a higher risk of dying from prostate cancer because higher grade disease may exist in unsampled portions of the prostate gland.
Our study found that there is an increased PCSM in men over the age of 70 and with low-risk Gleason score (GS) 6 prostate cancer. For this population there was a 10% increased risk per year that they have GS 7 or higher disease at radical prostatectomy (RP) and in men with GS 7 there was a 4% increased risk per year of age that they have GS 8 – 10 at RP. This supports the idea that these men may have more advanced disease initially that is missed on a standard 12-core biopsy. As such, in older men with low-risk disease who are considering active surveillance, an effort should be made to more rigorously evaluate the prostate gland. There are several new techniques that appear to be promising in regards to further evaluating the extent or aggressiveness of disease. Endorectal 3 T magnetic resonance imaging (MRI) has been shown to be 94% accurate in the staging of prostate cancer. Similarly, MRI-guided biopsy has been shown to detect significantly more GS 4/5 cancers than standard systematic biopsy and to have significantly greater accuracy. Apparent diffusion coefficients on MRI can aid in the detection of higher grade disease.
In summary, multiparametric MRI using 3T is a promising technique that may be useful in identifying older men with occult high-grade disease. Lastly, the use of biomarkers is another hopeful modality to aid in the detection of prostate cancer. Both prostate cancer antigen 3 (PCA3) and TMPRSS2-ERG have been correlated with higher-grade and higher-volume disease.[7, 8] Given the results from our study, we feel further investigation is warranted when men over the age of 70 are diagnosed with low-grade disease before placing them on active surveillance.
- National Institutes of Health State of the Science Conference: Role of Active Surveillance in the Management of Men with Localized Prostate Cancer, December 7, 2011, pp 1 - 17
- Cooperberg MR, Broering JM, Carroll PR: Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol 28:1117-23, 2010
- Berry SJ, Coffey DS, Walsh PC, et al. The development of human benign prostatic hyperplasia with age. J Urol 132:474-9, 1984
- Futterer JJ, Heijmink SW, Scheenen TW, et al. Prostate cancer: local staging at 3-T endorectal MR imaging--early experience. Radiology 238:184-91, 2006
- Haffner J, Lemaitre L, Puech P, et al. Role of magnetic resonance imaging before initial biopsy: comparison of magnetic resonance imaging-targeted and systematic biopsy for significant prostate cancer detection. BJU Int 108:E171-8, 2011
- Hambrock T, Somford DM, Huisman HJ, et al. Relationship between apparent diffusion coefficients at 3.0-T MR imaging and Gleason grade in peripheral zone prostate cancer. Radiology 259:453-61, 2011
- Lin DW, Newcomb, L.F., Brown, E.C. et al. Urinary TMPRSS2: Use of ERG and PCA3 to predict tumor volume and Gleason grade in an active surveillance cohort—Results from the Canary/EDRN Prostate Active Surveillance Study., 2012 Genitourinary Cancers Symposium San Francisco, CA, 2012
- Salagierski M, Schalken JA: Molecular Diagnosis of Prostate Cancer: PCA3 and TMPRSS2:ERG Gene Fusion. J Urol 187:795-801, 2012
Andrea L. Russo, 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.
Brigham and Women's Hospital
Department of Radiation Oncology
75 Francis St, ASB1-L2
Boston, MA 02215, USA