Abstract
BackgroundTo assess factors that can predict active surveillance (AS) failure on serial transrectal ultrasound guided biopsies in patients with low-risk prostate cancer.MethodsWe evaluated the records of 144 consecutive patients enrolled in AS between 2007 and 2014 at a single academic institution. Low risk inclusion criteria included PSA < 10 ng/ml, cT1c or cT2a, Grade Group (GG) 1, < 3 positive cores, and < 50% tumor in a single core with the majority having a PSA density of < 0.15. AS reclassification was defined as progression to GG ≥2, 3 or more cores, or core tumor volume ≥ 50%. Univariate and multivariate Cox proportional hazards regression analysis was used to determine predictors of reclassification and a match-pair analysis performed on a control group of patients choosing surgery.ResultsInclusion criteria were met by 130 men with a median follow-up of 52 months. The reclassification or AS failure rate was 38.5%, with the majority 41/50 (82%) finding GG ≥ 2 cancer. Most patients had unilateral disease on diagnostic biopsy (94.6%), but 40.7% had bilateral cancer detected during follow-up. Men with bilateral detected tumor were more likely to ultimately fail AS than patients with unilateral tumors (HR 4.089; P < 0.0001) and failed earlier with a reclassification-free survival of 32 vs 119 months respectively. In a matched-pair analysis using a population of 211 concurrent patients that chose radical prostatectomy rather than AS, 76% of patients with unilateral cancer on biopsy had bilateral cancer on final pathology.ConclusionsThe finding of bilateral prostate cancer on biopsy is associated with earlier AS reclassification. Finding bilateral disease may not represent disease progression, but rather enhanced detection of more extensive disease highlighting the importance of confirmatory biopsy.
Highlights
To assess factors that can predict active surveillance (AS) failure on serial transrectal ultrasound guided biopsies in patients with low-risk prostate cancer
Currently 15% men are diagnosed with prostate cancer (PC) during their lifetime but the risk of death due to the disease is only 3% [1]
Prostate Specific Antigen (PSA) density was low (< 0.15) for the majority of the population making it a less powerful indicator of failure in this population. This finding is supported by a study in which the presence of bilateral prostate cancer on biopsy was exchanged with > 50% maximal core involvement (MCI) as a reason for excluding AS excusion criteria, demonstrating good performace in predicting clinically significant prostate cancer [19]. These findings suggest that the presence of bilateral disease is a clinically significant and inexpensive way to risk stratify patients enrolled in AS
Summary
To assess factors that can predict active surveillance (AS) failure on serial transrectal ultrasound guided biopsies in patients with low-risk prostate cancer. 15% men are diagnosed with prostate cancer (PC) during their lifetime but the risk of death due to the disease is only 3% [1]. The average expected years of life lost due to PC is 1.8 years, compared to other common malignancies such as breast cancer, at 16.7 years [2]. To further emphasize this long natural history, up to 45% of patients are diagnosed with low risk PC [3]. Our hypothesis is that having a biopsy showing bilateral tumor would indicate multifocal PC, which may be associated with higher volume and higher stage disease compared to those with unilateral tumors on initial biopsy
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