scholarly journals Guy’s and St Thomas NHS Foundation active surveillance prostate cancer cohort: a characterisation of a prostate cancer active surveillance database

BMC Cancer ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Salonee Shah ◽  
Kerri Beckmann ◽  
Mieke Van Hemelrijck ◽  
Ben Challacombe ◽  
Rick Popert ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Active Surveillance ◽  
Specific Antigen ◽  
Future Research ◽  
Low Grade ◽  
Intermediate Risk ◽  
Psa Testing ◽  
Diagnostic Characteristics ◽  
Diagnostic Biopsy

Abstract Background The routine clinical use of serum prostatic specific antigen (PSA) testing has allowed earlier detection of low-grade prostate cancer (PCa) with more favourable characteristics, leading to increased acceptance of management by active surveillance (AS). AS aims to avoid over treatment in men with low and intermediate-risk PCa and multiple governing bodies have described several AS protocols. This study provides a descriptive profile of the Guy’s and St Thomas NHS Foundation Trust (GSTT) AS cohort as a platform for future research in AS pathways in PCa. Methods Demographic and baseline characteristics were retrospectively collected in a database for patients at the GSTT AS clinic with prospective collection of follow-up data from 2012. Seven hundred eighty-eight men being monitored at GSTT with histologically confirmed intermediate-risk PCa, at least 1 follow-up appointment and diagnostic characteristics consistent with AS criteria were included in the profile. Descriptive statistics, Kaplan-Meier survival curves and multivariable Cox proportion hazards regression models were used to characterize the cohort. Discussion A relatively large proportion of the cohort includes men of African/Afro-Caribbean descent (22%). More frequent use of magnetic resonance imaging and trans-perineal biopsies at diagnosis was observed among patients diagnosed after 2012. Those who underwent trans-rectal ultrasound diagnostic biopsy received their first surveillance biopsy 20 months earlier than those who underwent trans-perineal diagnostic biopsy. At 3 years, 76.1% men remained treatment free. Predictors of treatment progression included Gleason score 3 + 4 (Hazard ratio (HR): 2.41, 95% Confidence interval (CI): 1.79–3.26) and more than 2 positive cores taken at biopsy (HR: 2.65, CI: 1.94–3.62). A decreased risk of progressing to treatment was seen among men diagnosed after 2012 (HR: 0.72, CI: 0.53–0.98). Conclusion An organised biopsy surveillance approach, via two different AS pathways according to the patient’s diagnostic method, can be seen within the GSTT cohort. Risk of patients progressing to treatment has decreased in the period since 2012 compared with the prior period with more than half of the cohort remaining treatment free at 5 years, highlighting that the fundamental aims of AS at GSTT are being met. Thus, this cohort is a good resource to investigate the AS treatment pathway.

Overdiagnosis and Overtreatment of Prostate Cancer

2012 ◽  
pp. e35-e39 ◽  
Author(s):  
Ian M. Thompson
Keyword(s):  
Prostate Cancer ◽  
Active Surveillance ◽  
Specific Antigen ◽  
The United States ◽  
Assessment Tools ◽  
Low Grade ◽  
High Grade ◽  
Surveillance Strategy ◽  
Psa Testing ◽  
Prostate Cancer Prevention

Overview: Prostate cancer is a ubiquitous disease, affecting as many as two-thirds of men in their 60s. Through widespread prostate-specific antigen (PSA) testing, increasing rates of prostate biopsy, and increased sampling of the prostate, a larger fraction of low-grade, low-volume tumors have been detected, consistent with tumors often found at autopsy. These tumors have historically been treated in a manner similar to that used for higher-grade tumors but, more recently, it has become evident that with a plan of active surveillance that reserves treatment for only those patients whose tumors show evidence of progression, very high disease-specific survival can be achieved. Unfortunately, the frequency of recommendation of an active surveillance strategy in the United States is low. An alternative strategy to improve prostate cancer detection is through selected biopsy of those men who are at greater risk of harboring high-grade, potentially lethal cancer. This strategy is currently possible through the use of risk assessment tools such as the Prostate Cancer Prevention Trial Risk Calculator ( www.prostate.cancer.risk.calculator.com ) as well as others. These tools can predict with considerable accuracy a man's risk of low-grade and high-grade cancer, allowing informed decision making for the patient with a goal of detection of high-risk disease. Ultimately, other biomarkers including PCA3, TMPRSS2:ERG, and [-2]proPSA will likely aid in discriminating these two types of cancer before biopsy.

scholarly journals Current Status of MRI and PET in the NCCN Guidelines for Prostate Cancer

2019 ◽  
Vol 17 (5) ◽  
pp. 506-513 ◽  
Author(s):  
Brandon R. Mason ◽  
James A. Eastham ◽  
Brian J. Davis ◽  
Lance A. Mynderse ◽  
Thomas J. Pugh ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Active Surveillance ◽  
Specific Antigen ◽  
Transrectal Ultrasound ◽  
The United States ◽  
Current Status ◽  
Low Grade ◽  
Nccn Guidelines ◽  
Psa Testing ◽  
Pet Ct

Prostate cancer (PCa) represents a significant source of morbidity and mortality for men in the United States, with approximately 1 in 9 being diagnosed with PCa in their lifetime. The role of imaging in the evaluation of men with PCa has evolved and currently plays a central role in diagnosis, treatment planning, and evaluation of recurrence. Appropriate use of multiparametric MRI (mpMRI) and MRI-guided transrectal ultrasound (MR-TRUS) biopsy increases the detection of clinically significant PCa while decreasing the detection of clinically insignificant PCa. This process may help patients with clinically insignificant PCa avoid the adverse effects of unnecessary therapy. In the setting of a known PCa, patients with low-grade disease can be observed using active surveillance, which often includes a combination of prostate-specific antigen (PSA) testing, serial mpMRI, and, if indicated, follow-up systematic and targeted TRUS-guided tissue sampling. mpMRI can provide important information in the posttreatment setting, but PET/CT is creating a paradigm shift in imaging standards for patients with locally recurrent and metastatic PCa. This article examines the strengths and limitations of mpMRI for initial PCa diagnosis, active surveillance, recurrent disease evaluation, and image-guided biopsies, and the use of PET/CT imaging in men with recurrent PCa. The goal of this review is to provide a rational basis for current NCCN Clinical Practice Guidelines in Oncology for PCa as they pertain to the use of these advanced imaging modalities.

scholarly journals Active surveillance in patients with a PSA >10 ng/mL

2014 ◽  
Vol 8 (9-10) ◽  
pp. 702 ◽  
Author(s):  
Paul Toren ◽  
Lih-Ming Wong ◽  
Narhari Timilshina ◽  
Shabbir Alibhai ◽  
John Trachtenberg ◽  
...  
Keyword(s):  
Active Surveillance ◽  
Specific Antigen ◽  
Sufficient Evidence ◽  
Hazard Ratios ◽  
Diagnostic Biopsy ◽  
Selection Of Patients ◽  
Baseline Psa ◽  
Selection Of

Introduction: The use of prostate-specific antigen (PSA) in active surveillance (AS) for prostate cancer is controversial. Some consider it an unreliable marker and others as sufficient evidence to exclude patients from AS. We analyzed our cohort of AS patients with a PSA over 10 ng/mL.Methods: We included patients who had clinical T1c–T2a Gleason ≤6 disease, and ≤3 positive cores with ≤50% core involvement at diagnostic biopsy and ≥2 total biopsies. Patients were divided into 3 groups: (1) those with baseline PSA >10 ng/mL, (2) those with a PSA rise >10 ng/mL during follow-up; and (3) those with a PSA <10 ng/mL throughout AS. Adverse histology was defined as biopsy parameters exceeding the entry criteria limits. We further compared this cohort to a concurrent institutional cohort with equal biopsy parameters treated with immediate radical prostatectomy.Results: Our cohort included 698 patients with a median follow-up of 46.2 months. In total, 82 patients had a baseline PSA >10 ng/mL and 157 had a PSA rise >10 ng/mL during surveillance. No difference in adverse histology incidence was detected between groups (p = 0.3). Patients with a PSA greater than 10 were older and had higher prostate volumes. Hazard ratios for groups with a PSA >10 were protective against adverse histology. Larger prostate volume and minimal core involvement appear as factors related to this successful selection of patients to be treated with AS.Conclusion: These results suggest that a strict cut-off PSA value for all AS patients is unwarranted and may result in overtreatment. Though lacking long-term data and validation, AS appears safe in select patients with a PSA >10 ng/mL and low volume Gleason 6 disease.

Adverse pathology as a predictor of distant metastasis and prostate cancer mortality with 20-year follow up.

2021 ◽  
Vol 39 (6_suppl) ◽  
pp. 219-219
Author(s):  
Michael Austin Brooks ◽  
Lewis Thomas ◽  
Cristina Magi-Galluzi ◽  
Jianbo Li ◽  
Michael Crager ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Radical Prostatectomy ◽  
Active Surveillance ◽  
Distant Metastasis ◽  
Cancer Mortality ◽  
High Grade ◽  
Intermediate Risk ◽  
Sampling Weights ◽  
Prostate Cancer Mortality

219 Background: Adverse pathology (AP) at radical prostatectomy (RP) is often used as a proxy for long-term prostate cancer outcomes. The goal of this study was to assess the association of AP at RP, defined as high-grade (> Grade Group 3) and/or non-organ confined disease (pT3), with distant metastasis and prostate cancer death. Methods: A stratified cohort sample of 428 patients was used to evaluate the association of adverse pathology with the risk of distant metastases and prostate cancer-specific mortality over 20 years after prostatectomy in 2641 patients treated between 1987-2004. Cox regression of cause-specific hazards was used to estimate the absolute risk of both endpoints, with death from other causes treated as a competing risk. Subgroup analysis in patients with low/intermediate risk disease potentially eligible for active surveillance was performed. Results: Among the 428 patients, 343 had AUA Low or Intermediate risk disease and 85 had High risk disease. Median follow-up time was 15.5 years (IQR 14.6–16.6 years). Using the cohort sampling weights for estimation, at RP 29.8% of patients had high-grade disease, 42.3 % had non-organ confined disease, 19.3% had both, and thus 52.8% had AP. Adverse pathology was highly associated with metastasis and prostate cancer mortality in the overall cohort (HR 12.30, 95% CI 5.30-28.55, and 10.03, 95% CI 3.42-29.47, respectively, both p<0.001), and in the low/intermediate risk subgroup potentially eligible for active surveillance (HR 10.48, 95% CI 4.18-26.28, and 8.60, 95% CI 2.40-30.84, respectively, both p≤0.001). Conclusions: Adverse pathology at radical prostatectomy is highly associated with future development of metastasis and prostate cancer mortality and may be used as a short-term predictor of outcomes. [Table: see text]

scholarly journals PSA screening for prostate cancer

2017 ◽  
Vol 63 (8) ◽  
pp. 722-725 ◽  
Author(s):  
Marcus V. Sadi
Keyword(s):  
Quality Of Life ◽  
Prostate Cancer ◽  
Early Diagnosis ◽  
Prostate Specific Antigen ◽  
Specific Antigen ◽  
Low Grade ◽  
Psa Screening ◽  
Psa Testing ◽  
Baseline Values

Summary Screening of prostate cancer with prostate-specific antigen (PSA) is a highly controversial issue. One part of the controversy is due to the confusion between population screening and early diagnosis, another derives from problems related to the quality of existing screening studies, the results of radical curative treatment for low grade tumors and the complications resulting from treatments that affect the patient’s quality of life. Our review aimed to critically analyze the current recommendations for PSA testing, based on new data provided by the re-evaluation of the ongoing studies and the updated USPSTF recommendation statement, and to propose a more rational and selective use of PSA compared with baseline values obtained at an approximate age of 40 to 50 years.

Gleason upgrading with time in a large, active surveillance cohort with long-term follow-up.

2013 ◽  
Vol 31 (6_suppl) ◽  
pp. 1-1 ◽  
Author(s):  
Suneil Jain ◽  
Danny Vesprini ◽  
Alexandre Mamedov ◽  
D. Andrew Loblaw ◽  
Laurence Klotz
Keyword(s):  
Prostate Cancer ◽  
Active Surveillance ◽  
Linear Regression Analysis ◽  
Low Risk ◽  
Disease Rate ◽  
Intermediate Risk ◽  
Rate Of Increase ◽  
Long Term Follow Up

1 Background: Active surveillance (AS) is an accepted management strategy for localized prostate cancer. However, the rate of pathological upgrading has not been well described in mature study cohorts. Furthermore, concern exists over the possibility of prostate cancer dedifferentiation with time in patients on AS. Methods: Patients in our prospectively collected AS database with at least one repeat prostate biopsy were included. Linear regression analysis was used to estimate the proportion of patients upgraded (Gleason 6 to 3+4 or higher, Gleason 3+4 to 4+3 or higher) with time from diagnostic biopsy. Results: 593 of 862 patients in our cohort had at least one repeat biopsy. Median follow-up was 6.4 years (max. 20.2 years). The total number of biopsies ranged from 2 to 6. 20% of patients were intermediate risk, 0.3 % high risk, all others low risk. 31.2% of patients were upgraded during active surveillance. The proportion of patients upgraded increased with time, suggesting prostate cancer dedifferentiation occurred at a rate of 1.0%/year (95%CI -0.12 to 2.16%/year). The estimated rate of increase was 2.5 times higher in patients with intermediate risk disease at diagnosis (rate 1.9%/year, 95%CI -0.7-4.6) compared with those with low risk disease (rate 0.75%/year, 95%CI -0.5-2.0). Further analysis is underway. 62% of upgraded patients (n=114) went on to have active treatment. Patients who were upgraded and treated had significantly greater PSA velocities (median 1.2 ng/ml/y vs 0.42 ng/ml/y, p=0.01) and significantly higher Gleason scores when upgraded, than those who remained on surveillance (21.8% vs 2.8% Gleason 8-10, p<0.01). Conclusions: This is the largest re-biopsy cohort, with long-term follow-up, described to date, enabling the first estimates of prostate cancer dedifferentiation in patients on AS. Dedifferentiation rates appear higher in patients with intermediate risk prostate cancer compared with those who are low risk at baseline.

Associations between uncertainty, anxiety, and quality of life in men with favorable-risk prostate cancer on active surveillance: Two-and-a-half years' follow-up.

2014 ◽  
Vol 32 (4_suppl) ◽  
pp. 135-135
Author(s):  
Patricia A. Parker ◽  
John W. Davis ◽  
David Latini ◽  
George Baum ◽  
Xuemei Wang ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Prostate Cancer ◽  
Active Surveillance ◽  
Specific Antigen ◽  
Digital Rectal Examination ◽  
Study Entry ◽  
Illness Uncertainty ◽  
Disease Specific

135 Background: Active surveillance (AS) has emerged as a viable option for many men with early stage prostate cancer (PC). This approach of careful monitoring with prostate-specific antigen (PSA) level, digital rectal examination, and prostate biopsy may allow men to avoid or delay the potentially debilitating side effects of such aggressive treatments as surgery or radiation; however, AS may create uncertainty and anxiety for men with PC. We examined the associations between illness uncertainty and anxiety and general and PC-specific quality of life (QOL) of 191 men with favorable-risk PC participating in the AS program at MD Anderson Cancer Center. Methods: Men completed measures of uncertainty (Mishel Uncertainty in Illness Scale), anxiety (State-Trait Anxiety Inventory), and general (SF-12, Physical Health [PCS] and Mental Health Component Score [MCS]) and disease-specific (Expanded Prostate Index Composite [EPIC]) QOL questionnaires upon study entry and every 6 months. These results are through a 2.5 year follow-up. Results: Men were primarily (86%) white and an average age of 67.2 (SD=8.9). Average baseline PSA was 3.3 ng/mL (SD=1.6), 98% had a Gleason score of 6, and 85% had cT1c disease. Both general and PC-specific QOL were relatively unchanged across the 2.5 year study period, except for statistically significant declines in the EPIC Sexual score (p<0.05). Controlling for demographic (age, ethnicity) and clinical characteristics (study entry PSA, PSA density, testosterone, BMI, baseline number of biopsies, family history of cancer, whether patients were taking a 5-alpha-reductase inhibitor, and whether the tumor was reclassified during the study), illness uncertainty was a significant predictor of all EPIC summary scores, PCS, and MCS (all, p<0.05). Anxiety was also a significant predictor of all EPIC summary scores and MCS (all, p<0.05), but not PCS (p=0.08). Conclusions: Both increased anxiety and increased illness uncertainty were associated with poorer general and disease specific QOL. Interventions that focus on reducing uncertainty and anxiety may enhance the QOL of men on AS for PC.

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

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.

Performance of MRI-TRUS-guided fusion biopsy to detect progression on active surveillance for low- and intermediate-risk prostate cancer.

2015 ◽  
Vol 33 (7_suppl) ◽  
pp. 43-43
Author(s):  
Thomas P. Frye ◽  
Nabeel Ahmad Shakir ◽  
Steven Abboud ◽  
Arvin Koruthu George ◽  
Maria J Merino ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Active Surveillance ◽  
Low Risk ◽  
Intermediate Risk ◽  
Targeted Biopsy ◽  
Fusion Biopsy ◽  
Trus Biopsy ◽  
Guided Biopsy ◽  
Risk Prostate Cancer

43 Background: Active surveillance (AS) is an established treatment option for men with low risk prostate cancer. Its role in intermediate prostate cancer is still being investigated. Recent studies have shown that multiparametric-MRI (mp-MRI) along with MRI-TRUS fusion-guided biopsy may better assess risk in patients eligible for AS, compared to 12-core biopsy, due to improved detection of clinically significant cancers. The objective is to determine the performance of MRI-TRUS guided biopsy for men on AS with both low and intermediate risk disease. Methods: Between 2007-2014 men on AS were included if they had complete mp-MRI and pathology data for 2 or more MRI-TRUS biopsy sessions. Fusion guided biopsy procedures consisted of MRI identified targeted biopsies as well as random 12 core biopsies. Men were allowed to participate in AS with low and intermediate risk prostate cancer, Gleason score ≤ 3+4=7. Progression was defined by patients with initial Gleason 3+3=6 to any Gleason 4, and Gleason 3+4=7 disease progressing to a primary Gleason 4 or higher. Results: 89 men met our study criteria with an average age of 62 years old (range 45-79). 75 men had low risk Gleason 3+3=6 at the outset of AS by 1st biopsy session with a median PSA 5.1 ng/ml. The other 14 men had intermediate risk prostate cancer Gleason 3+4=7 at the outset of AS and a median PSA 4.6 ng/ml. During follow-up, 25 (33%) low risk men progressed to 3+4 or above at a median of 20.6 months. Of these, 19 were found by targeted biopsy. 6 (43%) of the intermediate risk men progressed to Gleason 4+3=7 at a median of 36.8 months. 4 of these progressed on targeted fusion biopsy. In the intermediate risk men, 84 random biopsy cores were require to detect 1 progression versus 15 targeted biopsy cores to detect 1 progression. Conclusions: The majority of patients on AS who progressed were identified by MRI-TRUS targeted biopsy. Less biopsy cores are required to detect progression with targeted biopsy. These results are preliminary and a larger cohort with longer follow-up would be beneficial.

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