Abstract
IntroductionWe analyzed whether expansion of existing active surveillance (AS) protocols to include men with biopsy Gleason score (GS) 3+4 prostate cancer (PCa) would significantly alter pathologic and biochemical outcomes of potential candidates of AS.MethodsAmong patients who underwent radical prostatectomy at our center between 2006 and 2013, we identified 577 patients (group A) who preoperatively fulfilled at least one of 6 different AS criteria. Also, we identified 217 patients (group B) with biopsy GS 3+4 but fulfilled non-GS criteria from at least one of 6 AS criteria. Designating group C as expanded group incorporating all patients in group A and B, we compared risk of unfavorable disease (pathologic GS ≥4+3 and/or pathologic T stage ≥pT3a) and biochemical recurrence (BCR)-free survival between groups.ResultsRates of unfavorable disease were not significantly different between patients of group A and C who met AS criteria from 5 institutions (all p>0.05), not including University of Toronto (p<0.001). Also BCR-free survivals were not significantly different between patients in group A and C meeting each of 6 AS criteria (all p>0.05). Among group B, PSAD>0.15 ng/mL/cm3 (p = 0.011) and tumor length of biopsy GS 3+4 core>4 mm (p = 0.007) were significant predictors of unfavorable disease. When these two criteria were newly applied in defining group B, rates of unfavorable disease in group A and B was 15.6% and 14.7%, respectively (p = 0.886).ConclusionOverall rate of pathologically aggressive PCa harbored by potential candidates for AS may not be increased significantly with expansion of criteria to biopsy GS 3+4 under most contemporary AS protocols. PSAD and tumor length of biopsy GS 3+4 core may be useful predictors of more aggressive disease among potential candidates for AS with biopsy GS 3+4.
Highlights
We analyzed whether expansion of existing active surveillance (AS) protocols to include men with biopsy Gleason score (GS) 3+4 prostate cancer (PCa) would significantly alter pathologic and biochemical outcomes of potential candidates of AS
Of the remaining 1434 patients, we identified 577 men who met at least one of AS selection criteria used by the following institutions: Johns Hopkins Medical Institution (Hopkins) [2], Memorial SloanKettering Cancer Center (MSKCC) [11], Prostate Cancer Research International: Active Surveillance (PRIAS) [3], University of Miami (Miami) [4], University of California, San Francisco (UCSF) [5], and University of Toronto (Toronto) [6]
Of the 577 patients in group A, 160, 417, 290, 265, 434, and 577 were observed to fulfill AS criteria used in Hopkins, MSKCC, PRIAS, Miami, UCSF, and Toronto, respectively (Table 1)
Summary
We analyzed whether expansion of existing active surveillance (AS) protocols to include men with biopsy Gleason score (GS) 3+4 prostate cancer (PCa) would significantly alter pathologic and biochemical outcomes of potential candidates of AS. Active surveillance (AS) is considered as a legitimate alternative to initial radical treatment in the management of lowrisk prostate cancer (PCa). Based upon criteria for defining clinically insignificant PCa, different centers have set forth variable selection criteria for AS, mostly incorporating low Gleason score (GS), low clinical stage, and low prostate-specific antigen (PSA) level with estimates of tumor volume from biopsy. In comparison of various criteria for AS, there is a definite trade-off between sensitivity and specificity for prediction of insignificant PCa [1]. Stricter criteria would limit the number of men offered AS while excluding some potential candidates. It still remains to be answered whether more stringent criteria is better
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