Comparison of Pathological and Oncologic Outcomes of Favorable Risk Gleason Score 3 + 4 and Low Risk Gleason Score 6 Prostate Cancer: Considerations for Active Surveillance

238 Background: Limited derived benefit from definitive treatment has been observed with respect to prostate cancer−specific mortality (PCSM) in those low−risk disease and only small absolute risk reductions in both overall PCSM and incidence of metastasis have been demonstrated. Thus, active surveillance (AS) strategies have been adopted to monitor for disease progression with intent for intervention at time of disease reclassification. Yet, the timing and frequency of surveillance remain without evidence-based standardization. We assessed the relationship between the frequency of surveillance prostate biopsies and the oncologic outcomes in those patients with low−risk prostate cancer (CaP) managed by AS. Methods: An IRB approved retrospective chart review identified 114 patients placed on AS for their CaP between November of 1997 and November of 2000. Of those, 96 patients meet study inclusion criteria mandating a Gleason sum of < 7, tumor presence in < 4 sextets, involvement of <50% of any single biopsy core. Eligible patients were surveyed by serum PSA, DRE, and surveillance TRUS−guided biopsies at physician determined intervals. Results: At diagnosis, the mean age was 70.3 (SD±5.3) years with a mean PSA value of 8.2 (SD±8.2) ng/dL. While on AS, patients underwent a median of 3.5 (SD±2.02) TRUS−guided biopsies; at a frequency approaching 1 biopsy every 18 months. At a median follow−up of 134.8 months (95%CI: 114.5, 148.7), multivariate analysis found more frequent prostatic biopsy acquisition to be inversely associated a worse prognosis with respect to both progression−free (p<0.0001) and overall survival (p=0.0002). Both progression−free (p<0.0001) and overall survival (p=0.0207) were progressively shorter as the interval between biopsies declined from greater than 2 years, to 1−2 years, and then less than 1 year. Conclusions: No survival advantage was achieved by frequent re−biopsy of the prostate. Patients biopsied more frequently were paradoxically found have poorer survival outcomes.

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Multiparametric prostate MRI and MRI/ultrasound fusion biopsy as tools to follow prostate cancer progression for men on active surveillance.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.4_suppl.63 ◽

2014 ◽

Vol 32 (4_suppl) ◽

pp. 63-63 ◽

Cited By ~ 2

Author(s):

Nabeel Shakir ◽

Annerleim Walton-Diaz ◽

Soroush Rais-Bahrami ◽

Baris Turkbey ◽

Jason Rothwax ◽

...

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Cancer Progression ◽

Predictive Value ◽

Low Risk ◽

Fusion Biopsy ◽

Trus Biopsy ◽

Risk Prostate Cancer ◽

Low Risk Prostate Cancer

63 Background: Active surveillance (AS) is an option for patients with low risk prostate cancer (PCa); however, determining disease progression is challenging. At the NCI, multiparametric MRI (MP-MRI) with our biopsy protocol (MR-US fusion-guided plus 12 core extended sextant biopsy) has been used to confirm eligibility for AS. We evaluated the utility of these modalities in monitoring patients on AS. Methods: Patients who underwent MP-MRI of the prostate with biopsy per our protocol between 2007-2012 were reviewed. We selected a subset who met Johns Hopkins criteria for AS (Gleason score≤6, PSA density≤0.15, tumor involvement of ≤2 cores, and ≤50% of any single core) by outside 12−core TRUS biopsy. Patients with Gleason score≤6 confirmed at first NCI biopsy session were followed with annual MP-MRI and biopsy. MRI progression was defined as an increase in MP-MRI suspicion level, lesion diameter, or number of lesions. Pathologic progression was defined as an increase to Gleason score≥7 in either 12-core or MR-fusion biopsy. We determined the association between MRI and pathologic progression. Results: 129 patients met JHU criteria for AS by outside biopsy. Mean age was 61.6 years and mean PSA 5.16ng/mL. 28/129 (21.7%) patients had Gleason score ≥7 at first NCI biopsy session.31 patients had at least two biopsy sessions (mean follow up 18 months, range 12-54 months) of which 9/31 (29%) increased in Gleason score, all to 3+4=7. Fusion biopsy detected more pathologic progression than did standard biopsy (Table). The positive predictive value of MP-MRI for pathologic progression was 50%, while the negative predictive value was 84%. The sensitivity and specificity of MP-MRI for increase in Gleason score was 67% and 73%, respectively. Conclusions: Stable findings on MP-MRI are associated with Gleason score stability in patients with low-risk PCa choosing AS. The majority of patients who had pathologic progression were detected on fusion biopsy, which may suggest that random biopsies are unnecessary in this population. Larger studies are needed to validate these findings. [Table: see text]

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Gleason score upgrade among 10,282 men who underwent surgery as initial treatment in 2010: A population-based study.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.4_suppl.72 ◽

2014 ◽

Vol 32 (4_suppl) ◽

pp. 72-72

Author(s):

Hong Zhang ◽

Edward M. Messing ◽

Hamza Ahmed ◽

Yuhchyau Chen

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Specific Antigen ◽

Low Risk ◽

Categorical Variables ◽

Intermediate Risk ◽

Time Of Surgery ◽

Significant Difference ◽

Risk Prostate Cancer

72 Background: Active surveillance is now accepted initial management for men who have localized prostate cancer with low risk of disease progression. Many criteria have been used for patient identification, including Gleason score (GS) obtained from prostate biopsy. Because of concerns of sampling error, some have recommended repeated biopsy before committing to active surveillance. However, there is limited information about the risk of missing high grade disease using the current standard biopsy approach. This study seeks to compare GS difference from biopsy and surgery to provide an estimated rate of GS upgrade. Methods: The Surveillance, Epidemiology, and End Results (SEER) program was used to identify men with American Joint Committee on Cancer stage T1-2cN0M0 prostate cancer diagnosed between January 2010 and December 2010. Patients who underwent prostatectomy were selected for further analysis. Based on prostate-specific antigen (PSA) levels and GS, cases were divided into low (PSA <=10 and GS <=6) and intermediate (10<PSA<=20 or GS=7) risk groups. The rates of GS upgrade were reported for each group. Chi-square tests were used to assess differences in categorical variables (e.g. age and race) between groups of GS upgrade and no change/downgrade. Results: A total of 10,282 men were evaluated, with 9.2% (n=942) having low-risk disease, and 90.8% (n=9340) having intermediate-risk disease. Among men with low-risk prostate cancer, 22.3% (n=210) had GS upgrade and 0.8% (n=8) had GS 8 disease. Among men with intermediate risk disease, 26.2% (n=2446) had GS upgrade and 2.3% (n=214) had GS 8 disease. There was no statistically significant difference in either age or race distribution among men who had GS upgrade versus no change or downgrade at the time of surgery. Conclusions: A substantial number of low- and intermediate-risk prostate cancer patients had GS upgrade at the time of surgery, but few had upgraded to GS 8 high risk disease. These observations suggest that repeat biopsy prior to active surveillance may not be necessary.

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Re: African American Men with Very Low-risk Prostate Cancer Exhibit Adverse Oncologic Outcomes After Radical Prostatectomy: Should Active Surveillance Still Be an Option for Them?

European Urology ◽

10.1016/j.eururo.2013.08.042 ◽

2013 ◽

Vol 64 (5) ◽

pp. 858-859

Author(s):

Brent K. Hollenbeck

Keyword(s):

Prostate Cancer ◽

African American ◽

Radical Prostatectomy ◽

Active Surveillance ◽

African American Men ◽

Low Risk ◽

Oncologic Outcomes ◽

Risk Prostate Cancer ◽

Low Risk Prostate Cancer

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Changes in Prostate Cancer Grade on Serial Biopsy in Men Undergoing Active Surveillance

Journal of Clinical Oncology ◽

10.1200/jco.2010.33.0134 ◽

2011 ◽

Vol 29 (20) ◽

pp. 2795-2800 ◽

Cited By ~ 125

Author(s):

Sima P. Porten ◽

Jared M. Whitson ◽

Janet E. Cowan ◽

Matthew R. Cooperberg ◽

Katsuto Shinohara ◽

...

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Sampling Error ◽

Survival Rates ◽

Specific Antigen ◽

Extended Period ◽

Low Risk ◽

Gleason Grade

Purpose Active surveillance is now considered a viable treatment option for men with low-risk prostate cancer. However, little is known regarding changes in Gleason grade on serial biopsies over an extended period of time. Patients and Methods Men diagnosed with prostate cancer between 1998 and 2009 who elected active surveillance as initial treatment, with 6 or more months of follow-up and a minimum of six cores at biopsy, were included in analysis. Upgrading and downgrading were defined as an increase or decrease in primary or secondary Gleason score. Means and frequency tables were used to describe patient characteristics, and treatment-free survival rates were determined by life-table product limit estimates. Results Three hundred seventy-seven men met inclusion criteria. Mean age at diagnosis was 61.9 years. Fifty-three percent of men had prostate-specific antigen of 6 ng/mL or less, and 94% had Gleason score of 6 or less. A majority of men were cT1 (62%), had less than 33% of biopsy cores involved (80%), and were low risk (77%) at diagnosis. Median number of cores taken at diagnostic biopsy was 13, mean time to follow-up was 18.5 months, and 29% of men had three or more repeat biopsies. Overall, 34% (129 men) were found to have an increase in Gleason grade. The majority of men who experienced an upgrade (81%) did so by their second repeat biopsy. Conclusion A proportion of men experience an upgrade in Gleason score while undergoing active surveillance. Men who experience early upgrading likely represent initial sampling error, whereas later upgrading may reflect tumor dedifferentiation.

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Comparison of pathological and oncologic outcomes in “favorable risk” GS 3+4 and low risk GS6 prostate cancer: considerations for active surveillance

AME Medical Journal ◽

10.21037/amj.2018.03.03 ◽

2018 ◽

Vol 3 ◽

pp. 49-49

Author(s):

Anthony Ta ◽

Sophie Riddell ◽

Lih-Ming Wong

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Low Risk ◽

Oncologic Outcomes

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African American Men With Very Low–Risk Prostate Cancer Exhibit Adverse Oncologic Outcomes After Radical Prostatectomy: Should Active Surveillance Still Be an Option for Them?

Journal of Clinical Oncology ◽

10.1200/jco.2012.47.0302 ◽

2013 ◽

Vol 31 (24) ◽

pp. 2991-2997 ◽

Cited By ~ 151

Author(s):

Debasish Sundi ◽

Ashley E. Ross ◽

Elizabeth B. Humphreys ◽

Misop Han ◽

Alan W. Partin ◽

...

Keyword(s):

Prostate Cancer ◽

African American ◽

Radical Prostatectomy ◽

Active Surveillance ◽

White Men ◽

Low Risk ◽

Oncologic Outcomes ◽

Pathologic Features ◽

Risk Prostate Cancer ◽

Low Risk Prostate Cancer

Purpose Active surveillance (AS) is a treatment option for men with very low–risk prostate cancer (PCa); however, favorable outcomes achieved for men in AS are based on cohorts that under-represent African American (AA) men. To explore whether race-based health disparities exist among men with very low–risk PCa, we evaluated oncologic outcomes of AA men with very low–risk PCa who were candidates for AS but elected to undergo radical prostatectomy (RP). Patients and Methods We studied 1,801 men (256 AA, 1,473 white men, and 72 others) who met National Comprehensive Cancer Network criteria for very low–risk PCa and underwent RP. Presenting characteristics, pathologic data, and cancer recurrence were compared among the groups. Multivariable modeling was performed to assess the association of race with upgrading and adverse pathologic features. Results AA men with very low–risk PCa had more adverse pathologic features at RP and poorer oncologic outcomes. AA men were more likely to experience disease upgrading at prostatectomy (27.3% v 14.4%; P < .001), positive surgical margins (9.8% v 5.9%; P = .02), and higher Cancer of the Prostate Risk Assessment Post-Surgical scoring system (CAPRA-S) scores. On multivariable analysis, AA race was an independent predictor of adverse pathologic features (odds ratio, [OR], 3.23; P = .03) and pathologic upgrading (OR, 2.26; P = .03). Conclusion AA men with very low–risk PCa who meet criteria for AS but undergo immediate surgery experience significantly higher rates of upgrading and adverse pathology than do white men and men of other races. AA men with very low–risk PCa should be counseled about increased oncologic risk when deciding among their disease management options.

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