Management Of Low-risk Prostate Cancer Research Articles

A randomized, double-blind, placebo-controlled trial of metformin in reducing progression among men on expectant management for low-risk prostate cancer: The MAST (Metformin Active Surveillance Trial) study.

LBA5002 Background: Active Surveillance (AS) involves vigilant monitoring of selected prostate cancer (PCa) patients, with radical treatment initiation upon significant disease progression. AS eligibility varies, generally including low-risk PCa men. Metformin, a widely-used oral hypoglycemic agent, is known for its excellent tolerability and efficacy in diabetes management. Extensive preclinical data suggested that metformin may slow PCa progression. The purpose of this study is to examine the effect of metformin on the rates of progression among men with low-risk localized PCa on AS. Methods: A randomized double blind placebo controlled trial was carried out in 14 centres across Canada.Eligible patients had biopsy-proven, low-risk, localized PCa diagnosed within the past 6 months, with a Gleason score of <6 observed in ≤1/3 of the total cores, less than 50% positivity in any one core, a PSA level of ≤10 ng/ml, and a clinical stage between T1c-T2a. Additionally, they chose active surveillance as their primary treatment. Subjects that met eligibility criteria were randomly assigned (1:1) to receive metformin 850 mg BID or placebo for 3 years. All patients underwent repeat prostate biopsy at 18 and 36 months. The primary endpoint indicated was time to progression, defined as the earliest occurrence of primary PCa therapy (e.g., prostatectomy, radiation, hormonal therapy) or pathological progression (>1/3 of total cores involved, at least 50% of any one core involved, or Gleason pattern 4 or higher). Results: In our cohort of 407 patients, 204 were administered metformin, and 203 received a placebo. The median age of the overall cohort was 63 years. Out of the total 407 patients, 141 experienced disease progression. There was no statistically significant difference in progression-free survival (PFS) observed between patients treated with metformin and those receiving placebo (p=0.63). Conclusions: Despite tantalizing preclinical and epidemiological data, metformin consumption does not alter rates of progression among men with low risk PCa on AS. Clinical trial information: NCT01864096 .

A prospective cohort of men with localized prostate cancer on active surveillance protocol in Hong Kong, China: what did we learn?

This study aimed to report the outcomes of active surveillance (AS) in the management of low-risk prostate cancer (PCa). It recruited 87 men who were prospectively followed up according to the Prostate Cancer Research International Active Surveillance (PRIAS) protocol with local adaptation at SH Ho Urology Centre, Prince of Wales Hospital, Hong Kong, China. We investigated the predictors of disease progression and found that baseline prostate-specific antigen density (PSAD) and the presence of the highest Prostate Imaging-Reporting and Data System (PI-RADS) score 5 lesion on magnetic resonance imaging (MRI) are significantly correlated with disease progression. Moreover, men with PSAD >0.2 ng ml -2 or PI-RADS 4 or 5 lesions had significantly worse upgrading-free survival compared to those with PSAD ≤0.2 ng ml -2 and PI-RADS 2 or 3 lesions. The study concludes that AS is a safe and effective management strategy for selected patients to defer radical treatment and that most disease progression can be detected after the first repeated biopsy. The combination of PSAD >0.2 ng ml -2 and PI-RADS 4 or 5 lesions may serve as a useful predictor of early disease progression and provide a guide to optimize follow-up protocols for men in different risk groups.

Increasing Use of Conservative Management of Low-Risk Prostate Cancer in the Veterans Affairs System from 2012 to 2021

Conservative management (CM), including either active surveillance or watchful waiting, is the preferred management strategy for men with low-risk prostate cancer. We sought to describe contemporary trends in CM among men with localized prostate cancer across the equal-access Veterans Affairs (VA) system. Using VA tumor registry data, we identified all men with a new diagnosis of biopsy-proven, clinically node-negative, non-metastatic prostatic adenocarcinoma from 2012 to 2021, excluding men with missing National Comprehensive Cancer Network risk group. We quantified the yearly proportion of patients with low and favorable intermediate-risk (FIR) prostate cancer undergoing conservative management and examined age-specific rates. Multivariable logistic regression was used to identify independent clinical predictors of CM among men with low-risk and FIR disease. The cohort included 86,415 patients with localized prostate cancer, of whom 20,290 (23.5%) had low risk and 25,447 (29.5%) had FIR disease. The proportion of men diagnosed with low-risk disease decreased from 27.7% in 2012 to 20.1% in 2021. The proportion of men with localized prostate cancer who were 70 years or older at diagnosis increased from 19.5% in 2012 to 46.4% in 2021, with similar increases seen across risk groups. The proportion of men with low-risk disease undergoing CM increased from 63.1% in 2012 to 86.6% in 2021. CM rates in 2021 among low-risk patients were largely consistent across age groups (50-59: 85.1%; 60-69: 87.4%; 70+: 86.3%). For FIR patients, CM rates increased among the subset with Gleason 6 disease (49.5% in 2012 to 80.7% in 2021). In multivariable models, independent predictors of CM in low-risk patients included older age, more recent year, lower PSA at diagnosis, North Atlantic or Pacific region, and presence of another cancer at diagnosis; similar predictors were found in FIR patients. Self-reported race (Black, White, or Other) was not associated with CM. While there was wide geographic variation in CM rates among low-risk patients early in the study period (2012-2014: 56.1% in Southeast region vs 74.1% in Pacific), these disparities resolved in recent years (2019-2021: 83.2% in Southeast vs 83.8% in Pacific). Rates of conservative management for localized prostate cancer increased dramatically over time in the VA, with over 85% of low-risk patients managed conservatively in 2021. Recent years showed no differences in CM rates by self-reported race, geographic region, or age group. Despite this progress, we observed a concomitant increase in the proportion of men 70 years or older diagnosed with localized prostate cancer, including low risk disease. This raises a need to consider strategies to reduce the diagnosis of low-risk disease in elderly Veterans.

Uncovering the Changing Treatment Landscape for Low-risk Prostate Cancer in the USA from 2010 to 2020: Insights from the National Cancer Data Base

The management of prostate cancer (PCa) has evolved from a paradigm of “treat when caught early” to “treat only when necessary”. Despite inconsistency in its use, active surveillance has evolved over the past two decades into the gold standard for management of low-risk PCa. Our objective was to investigate whether the use of expectant management (active surveillance, watchful waiting, no treatment) as a first-line approach for low-risk PCa has increased over the past decade. We queried the US National Cancer Data Base for men diagnosed with localized PCa between 2010 and 2020. Two multivariable logistic regression models with different two-way interaction terms (year of diagnosis × D’Amico risk classification, and year of diagnosis × International Society of Urological Pathology [ISUP] grade group) were fitted to predict the probability of undergoing expectant management versus active treatment. The predicted probability of expectant management increased from 13.7% in 2010 to 64.4% in 2020 for men with low-risk PCa, and from 12.9% in 2010 to 61.6% in 2020 for ISUP grade group 1 PCa (both pinteraction < 0.001). The frequency of expectant management for low-risk PCa has increased dramatically during the past decade. We expect this trend to further increase owing to the growing awareness of the harms of overtreatment of indolent disease. Patient summaryWe examined the use of expectant management for prostate cancer between 2010 and 2020 in a large hospital-based registry from the USA. We found that the proportion of men receiving expectant management for low-risk prostate cancer is increasing. We conclude that growing awareness of the harms of overtreatment has profoundly affected trends for prostate cancer treatment in the USA.

Physician Perception of Grade Group 1 Prostate Cancer

BackgroundDespite its low-risk nature, grade group 1 (GG 1) prostate cancer (PCa) remains overtreated. This suggests a disconnect between daily physician practice and the standard of care. We hypothesized that GG 1 disease is overtreated because of common misconceptions regarding its true natural history. ObjectiveTo survey physicians worldwide to better understand their approach to management of GG 1 PCa. Design, setting, and participantsA 17-question survey was sent to urology, radiation oncology, and pathology societies on six continents, and was posted on Twitter. Responses were collected and analyzed. Outcome measurements and statistical analysisPearson’s χ2 test was used to assess correlation between physician-related variables and the perception of active surveillance (AS) for GG 1 PCa. Logistic regression was used for multivariable analysis. Statistical analysis was performed using SPSS version 21. Results and limitationsAmong 1303 participants, 55% were urologists, 47% had completed fellowship, and 49% practice in an academic setting. Among the clinicians, 724 (83%) routinely recommend AS for GG 1 PCa and have never/rarely regretted it, while 18 (2%) “often” regretted it. Routine AS was more common among physicians aged <40 yr, those in practice for <10 yr, and those living in North America, Europe, or Australia/New Zealand. More than one-third of the respondents practicing in nonacademic settings reported 15-yr PCa mortality in low-risk PCa of >3%. Regarding reclassification of GG 1 to a precancerous lesion, 428 (39%) felt that this is a good idea, 340 (31%) disagreed, and 323 (30%) were uncertain. Those in support were more likely to be aged <40 yr (p = 0.001), in practice for <5 yr (p = 0.005), urologists (p < 0.001), and fellows trained in urologic oncology (p < 0.001). Opposition was common among pathologists (61%). Among terminologies proposed to replace “cancer” for GG 1 are neoplasm of low malignant potential (51% approval), indolent neoplasm rarely requiring treatment (23%), and indolent lesion of epithelial origin (8%). ConclusionsAS is more commonly recommended by physicians who are younger, are fellowship-trained in urologic oncology, practice in academic settings, and are based in North America, Europe, or Australia/New Zealand. Misconceptions regarding AS outcomes may hinder its adoption. Frequent use of AS is associated with support for changing the “cancer” nomenclature. Patient summaryIn this study, we found that active surveillance remains underused in the management of low-risk prostate cancer because of incorrect perceptions regarding cancer outcomes. Omitting the word “cancer” for low-risk lesions is a challenging but promising effort that is favored by many clinicians, particularly by those who advocate for active surveillance.

MP38-14 UNITED STATES INSTITUTIONAL VARIATION IN THE USE OF ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER

You have accessJournal of UrologyCME1 Apr 2023MP38-14 UNITED STATES INSTITUTIONAL VARIATION IN THE USE OF ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER Shu Wang, Amir Khan, Kathryn Hughes Barry, Michael Naslund, and M. Minhaj Siddiqui Shu WangShu Wang More articles by this author , Amir KhanAmir Khan More articles by this author , Kathryn Hughes BarryKathryn Hughes Barry More articles by this author , Michael NaslundMichael Naslund More articles by this author , and M. Minhaj SiddiquiM. Minhaj Siddiqui More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003276.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Active surveillance (AS) has been recommended as the initial management for low-risk prostate cancer (PCa). Even though we have witnessed a dramatic increase in the use of AS recently, significant variation still exists. This study aimed to investigate the use of AS for low-risk prostate cancer at the institutional level. METHODS: The National Cancer Database was used to identify patients diagnosed with low-risk prostate adenocarcinoma (NCCN criteria: cT1-cT2a, PSA<10, Gleason Score 3+3) as the only malignancy from 2015 to 2019. Patients aged 40-75 were included. Information on the initial management was accessed. The AS rate on the institute level was calculated as the number of patients on AS divided by the total number of patients with low-risk PCa reported by a specific institute. We only included institutions with a cohort of no less than ten patients. RESULTS: 1,010 institutions with 85,026 low-risk PCa patients were included in this study. The mean AS rates on the institutional level were 38% (IQR 15-55%), 36% (IQR 8-63%), 27% (IQR 5-44%), and 26% (IQR 3-45%), among Academic/Research Programs, Community Cancer Programs, Integrated Network Cancer Programs, and Comprehensive Community Cancer Programs, respectively (p<0.001). When stratifying centers based on the AS uptake rates, we found that 35% (350/1010) of institutions reported a very low AS rate (<10%), 28% (287/1010) reported a low AS rate (10-40%), 33% reported a suboptimal AS rate (40-80%) and only 4% achieved an optimal AS rate (>80%). The percentages of each institutional type stratified by AS rates are shown in Figure 1. Comprehensive Community Cancer Programs had the highest percentage (42%) of institutions with very low AS rates, and Community Cancer Programs had the highest percentage meeting an optimal AS rate (10%). CONCLUSIONS: Significant variations of AS for low-risk PCa were observed at the institutional level. A substantial number of institutions still demonstrate very low rates of <10% of AS for management of low-risk PCa. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e529 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shu Wang More articles by this author Amir Khan More articles by this author Kathryn Hughes Barry More articles by this author Michael Naslund More articles by this author M. Minhaj Siddiqui More articles by this author Expand All Advertisement PDF downloadLoading ...

Time Trends and Variation in the Use of Active Surveillance for Management of Low-risk Prostate Cancer in the US

Active surveillance (AS) is endorsed by clinical guidelines as the preferred management strategy for low-risk prostate cancer, but its use in contemporary clinical practice remains incompletely defined. To characterize trends over time and practice- and practitioner-level variation in the use of AS in a large, national disease registry. This retrospective analysis of a prospective cohort study included men with low-risk prostate cancer, defined as prostate-specific antigen (PSA) less than 10 ng/mL, Gleason grade group 1, and clinical stage T1c or T2a, newly diagnosed between January 1, 2014, and June 1, 2021. Patients were identified in the American Urological Association (AUA) Quality (AQUA) Registry, a large quality reporting registry including data from 1945 urology practitioners at 349 practices across 48 US states and territories, comprising more than 8.5 million unique patients. Data are collected automatically from electronic health record systems at participating practices. Exposures of interest included patient age, race, and PSA level, as well as urology practice and individual urology practitioners. The outcome of interest was the use of AS as primary treatment. Treatment was determined through analysis of electronic health record structured and unstructured clinical data and determination of surveillance based on follow-up testing with at least 1 PSA level remaining greater than 1.0 ng/mL. A total of 20 809 patients in AQUA were diagnosed with low-risk prostate cancer and had known primary treatment. The median age was 65 (IQR, 59-70) years; 31 (0.1%) were American Indian or Alaska Native; 148 (0.7%) were Asian or Pacific Islander; 1855 (8.9%) were Black; 8351 (40.1%) were White; 169 (0.8%) were of other race or ethnicity; and 10 255 (49.3%) were missing information on race or ethnicity. Rates of AS increased sharply and consistently from 26.5% in 2014 to 59.6% in 2021. However, use of AS varied from 4.0% to 78.0% at the urology practice level and from 0% to 100% at the practitioner level. On multivariable analysis, year of diagnosis was the variable most strongly associated with AS; age, race, and PSA value at diagnosis were all also associated with odds of surveillance. This cohort study of AS rates in the AQUA Registry found that national, community-based rates of AS have increased but remain suboptimal, and wide variation persists across practices and practitioners. Continued progress on this critical quality indicator is essential to minimize overtreatment of low-risk prostate cancer and by extension to improve the benefit-to-harm ratio of national prostate cancer early detection efforts.

Evolving Trends in the Management of Low-Risk Prostate Cancer.

Deferred treatment is a growing management strategy for low-risk prostate cancer. However, it is unknown whether this growth is mediated by patient factors. In this study, we sought to evaluate factors associated with deferred treatment in patients with low-risk prostate cancer and shifts in these factors after recent incorporation of active surveillance into national guidelines. We identified 137,915 men diagnosed with low-risk prostate cancer (prostate-specific antigen <10 ng/mL, Gleason score ≤6, stage cT1-cT2a) in the National Cancer Database from 2010 to 2017. Multivariate logistic regression models were used to determine factors associated with deferred treatment. Interaction variables were added to determine whether trends in use of deferred treatment over time depend on race, income, education, and insurance status. The use of deferred treatment among men with low-risk prostate cancer increased from 14.7% in 2010-2011 to 46.3% in 2016-2017 (P < .001). On multivariate analysis, deferred treatment was associated with older age, more contemporary year of diagnosis, black race, lower income, higher educational attainment, government insurance, being uninsured, treatment at an academic/research facility, and treatment at a facility in New England (each P < .05). Incorporation of interaction variables showed that black race, belonging to the two lowest income quartiles, government insurance, and being uninsured became less associated with deferred treatment in recent years. The use of deferred treatment among men with low-risk prostate cancer increased significantly from 2010 to 2017. However, patients who were black, low-income, and not privately insured experienced smaller increases in deferred treatment. Interventions to increase uptake in these groups present opportunities to improve quality of care.

The evolving landscape of practice pattern and survival outcomes in the management of localized low-risk prostate cancer.

e17057 Background: The majority of patients with low-risk prostate cancer (LRPC) are candidates for active surveillance (AS) or definitive local treatment, which may include radical prostatectomy (RP), external beam radiotherapy (EBRT), or prostate seed implant (PSI). In the recent edition of the National Comprehensive Cancer Network (NCCN) guidelines, the “preferred” status was removed for AS, which rekindled a debate and interest in the management of LRPC. In this study, we analyzed the treatment pattern and impact of various treatment modalities on the survival of patients with LRPC using a large patient population provided by the National Cancer DataBase (NCDB). Methods: Patients with LRPC, as defined by the NCCN criteria, between 2004 and 2015 from NCDB were analyzed. Patients are categorized by treatment modalities, including RP, EBRT, PSI, and those who received no local therapy (NLT). Only patients with low Charlson-Deyo comorbidity score, 0 or 1 were included to ensure comparability between treatment groups. A multivariable Cox regression model was developed to determine the adjusted odds of patients' survival. The Kaplan Meier survival plots stratified by treatment were generated to establish the median overall survival (OS). The log-rank test was used to determine significance between treatment groups. Cox regression models were used to produce parameter estimates and hazard ratio (HR) for each age group. Results: A total of 195,452 patients with LRPC were identified from 2004 to 2015. There was a significant practice pattern change with increased utilization of NLT over time, from 11.3% in 2004 to 53.5% in 2015, with a turning point in 2009. The utilization was peaked for RP at 41.6% in 2008, EBRT at 24.3% in 2006, and PSI at 35.3% in 2004, but dropped to 17.6%, 18.1%, and 10.8%, respectively, in 2015. Of different treatment modalities, compared to NLT, RP provided a superior OS with a HR of 0.662, p &lt; .0001; PSI also improved OS with an HR of 0.795, p &lt; .0001. However, EBRT did not improve OS and was potentially detrimental, HR = 1.049, p = 0.01. With age-matched subgroup analysis, the survival advantage based on HR of RP relative to NLT favors RP until the age of 74 but diminishes as age increases. In patients younger than 70, NLT provided comparable survival to EBRT or PSI. The survival advantage of EBRT or PSI is only seen in older patients, at age of 75 or older for EBRT and 70 or older for PSI. Conclusions: There has been a significant treatment pattern change between 2004 and 2015. AS, as represented by the NLT in this study, has become the dominant choice of treatment for LRPC. However, of different treatment modalities, both RP and PSI improve OS. The patients managed with AS had comparable OS to those who received EBRT. The survival benefit of RP is mostly seen in younger patients. Only older patients benefit from PSI or EBRT. This study is limited by its retrospective nature and inherent bias in NCDB.

Large variation in conservative management of low-risk prostate cancer in Australia and New Zealand.

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Does Protocol Make a Difference? Comparison of Two Prostate Cancer Active Surveillance Cohorts: A Non–protocol-based Follow-up and a Protocol-based Contemporary Follow-up

BackgroundActive surveillance (AS) is the preferred option for initial management for low-risk prostate cancer (PC). Although many AS protocols exist, there is little evidence to support one over another. ObjectiveTo assess whether there is difference in overall (OS), prostate cancer–specific (CSS), metastasis-free (MFS), or treatment-free (TFS) survival between a strict (Prostate cancer Research International: Active Surveillance [PRIAS]) and a loose (European Randomized study of Screening for Prostate Cancer [ERSPC]) AS protocol. Design, setting, and participantsThis study included two cohorts of men (n = 518) with low-risk, localized, Gleason score ≤7 PC. The ERSPC cohort included 241 men followed for 9.5 yr (median) with a non–protocol-based follow-up. The PRIAS cohort included 277 men followed for 5 yr (median) with a strict protocol. Outcome measurements and statistical analysisOS, CSS, MFS, and TFS were compared by the Kaplan-Meier method, competing risk analysis, and Cox proportional hazard regression. Results and limitationsAs expected, due to the difference in median follow-up time between the cohorts, a difference in the absolute number of events was seen. However, no difference in any of the survival outcomes was evident in the Kaplan-Meier or competing risks analysis. Furthermore, in Cox proportional hazard regression analysis, cohort (ERSPC vs PRIAS) was not associated with any of the outcomes. Results are limited by the retrospective study design, limited statistical power, and inability to match the cohorts for predictive factors. ConclusionsThere was no difference in survival outcomes between a non–protocol-based follow-up and a protocol-based contemporary AS follow-up of patients with low-risk PC. However, a longer follow-up is needed. Patient summaryWe compared survival outcomes of two cohorts of patients with low-risk prostate cancer: a strict and a loose follow-up protocol. We found no differences in survival measures between the cohorts.

Temporal trends in the number of men electing for conservative management for low-risk prostate cancer in the United States.

Concurrent with the decrease in the number of men diagnosed with prostate cancer (PCa), the proportion of men with low-risk PCa managed conservatively (active surveillance or watchful waiting) has increased in the United States. We aimed to determine whether this increase is a result of more men being managed conservatively or rather a higher proportion of the diminishing number of low-risk PCa managed this way. The SEER "Prostate Watchful Waiting Database" identified men managed initially with conservative management between 2010 and 2016. Men > 40 years old who were diagnosed with low-risk (Gleason score 3 + 3, T1-T2a, PSA level < 10 ng/mL) PCa were included. Age-standardized and age-specific PCa incidence and conservative management rates were calculated per 100,000 man-years. The annual percent change in rates for the entire time period was also calculated. The incidence of low-risk PCa declined by 11.8% per year (95% confidence interval [CI] -15.4% to -8.0%), whereas the number of men assigned to conservative management for low-risk disease did not increase significantly, rising by +3.7% per year (95% CI -0.7% to 8.4%). In age-specific analysis, the number of men < 60 years and those who were 60-69 years managed conservatively increased by +9.6% per year (95% CI 2.7% to 16.9%) and 4.5% per year (95% CI 0.1% to 9.1%), respectively, whereas the number of men ≥ 70 years electing conservative management remained stable at -4% per year (95% CI -11.2% to 3.7%). The number of men electing conservative management has remained largely stable between 2010 and 2016, despite an increase in the proportion of low-risk PCa managed in this manner.

Active surveillance for low-risk prostate cancer - in pursuit of a standardized protocol.

IntroductionActive surveillance (AS) is a management option recommended by most guidelines for low risk clinically-localized prostate cancer (LR-CLPC). Data shows that AS is being increasingly adopted into clinical practice worldwide. Our aim was to review the up-to date guidelines and observational studies in regards to AS in LR-CLRPC to gain insight into principles of contemporary clinical practice.Material and methodsSeveral guidelines on the management of low-risk prostate cancer were reviewed for evidence-based recommendations regarding the protocol of AS. We reviewed the available literature for most recent studies on AS in LR-CLPC.ResultsNo uniform protocol of AS in LR-CLPC has been recommended up to date and available guidelines significantly differ in terms of protocol schedules and the role of particular tools in monitoring for disease progression. Nevertheless, recent studies on AS in LR-CLPC, in which various protocols were adopted, have demonstrated promising outcomes in regards to cancer-specific survival (99–100% at 5 years, 98.1–99.9% at 10 years, and 94.3–96% at 15 years), with high rates of men remaining within the protocols (23–39% at 10 years).ConclusionsThis article is a call for focusing further research on development and recommending a precise and standardized, evidence-based protocol for AS in LR-CLPC.

Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario.

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.

Management of low-risk prostate cancer in patients with enlarged glands and lower urinary tract symptoms: robotic total prostatectomy, a novel technique.

Low-risk prostate cancer (PCa) is primarily managed with Active Surveillance (AS). A subset of these patients have significantly enlarged glands and lower urinary tract symptoms (LUTS) recalcitrant to medical therapy. Radical treatment in this patient population risks compromise to both erectile function and continence. Therefore, our primary aim is to introduce a novel surgical technique, robotic total prostatectomy (RTP), for the management of severely enlarged prostate hyperplasia with concomitant suspicion of low-risk prostate cancer. After IRB approval and patient consultation/education, we performed RTP on 12 consecutive patients who presented with low-risk PCa and significantly enlarged prostate glands with LUTS. Inclusion criteria included patients with suspicion of low-risk malignancy, subjective/objective complaint of LUTS, and pre-operative prostate size > 60 g. Preoperative, perioperative and postoperative variables were studied in the following domains: surgical, oncologic, continence and erectile function. A total of 12 patients underwent RTP. Mean preoperative prostate volume and PSA was estimated at 96.96 g and 8.79, respectively. Surgical time, EBL and LOS was estimated at 180.8min, 189.6ml, and 2days, respectively. Post-operative variables confirmed resolution of LUTS (mean PVR 41.78/IPSS 8.3) and efficient oncologic control (mean PSA 0.04), with minimal compromise of sexual function. 100% continence was achieved at 3months. RTP is a novel, efficient surgical procedure for the treatment of patients with at-risk for low-grade malignancy and symptomatic LUTS in an enlarged gland. Expanding the indication to patients with low-risk malignancy, irrespective of prostate size may alleviate the adverse effects of radical treatment in this select subset of patients.

Conservative Management for Low-Risk Prostate Cancer in Black Patients: A Population-Based Analysis

Conservative Management for Low-Risk Prostate Cancer in Black Patients: A Population-Based Analysis

SBRT as Monotherapy or Boost for Intermediate or High-Risk Prostate Cancer: A Prospective Observational Study

The high level of precision and accuracy of Stereotactic Body Radiotherapy (SBRT,) in addition to its unique radiobiologic characteristics, confer a potential therapeutic advantage with limited toxicity when compared with alternated radiation therapy treatment approaches. Stereotactic Body Radiation Therapy (SBRT) has become a standard treatment alternative to other treatment options such as laparoscopic-assisted robotic prostatectomy, intensity-modulated radiation therapy (IMRT) and brachytherapy in the management of low-risk prostate cancer. The efficacy and risk profile of SBRT in the setting of intermediate and high-risk prostate cancer are less well studied. The purpose of this project is to evaluate the efficacy and Health-Related Quality of Life (HRQOL) in intermediate and high-risk prostate cancer patients treated with SBRT as monotherapy or as a boost in combination with IMRT. 77 patients with intermediate and high-risk prostate cancer were enrolled in this prospective evaluation Intermediate-risk patients (n=47, 61%)) were treated with SBRT monotherapy, 36.25 Gy in 5 fractions, or with SBRT boost to the prostate, 21 Gy in 3 fractions followed by IMRT directed to the prostate and seminal vesicles, 45 Gy in 25 fractions, per physician discretion. High risk patients (n=30, 39%) were treated with SBRT boost to the prostate, 21 Gy in 3 fractions followed by IMRT directed to the prostate, seminal vesicles and pelvic lymph nodes, 45 Gy in 25 fractions. Androgen deprivation hormonal therapy (ADT) was administered to all patients in the high-risk group and per physician discretion in the intermediate-risk group. Biochemical disease-free survival (bDFS) was calculated per the Phoenix definition. Quality of Life (QOL) was assessed by the American Urological Association (AUA) symptom index, Expanded Prostate cancer Index Composite Short Form (EPIC-26), and the Sexual Health Inventory for Men (SHIM). Acute and late genitourinary (GU) and gastrointestinal (GI) toxicity were graded using the CTCAE version 3.0 and RTOG/ECOG definitions. QOL was estimated using least square means of fixed effects. The median follow-up time was 18 months. The bDFS was 96.43%, 100% and 92.59% for favorable-intermediate, unfavorable-intermediate, and high-risk groups, respectively. Late Grade 2 and 3 genitourinary toxicities were 24%, and 1.2 %, and late grade 2 gastrointestinal toxicities were 3% without grade 3 toxicities reported. Mean EPIC QOL scores declined modestly at 1-month post-treatment, plateaued until about 24 months, and recovering to levels close to baseline thereafter. SBRT as monotherapy or boost in the management of intermediate or high-risk patients with adenocarcinoma of prostate is a promising treatment approach, with excellent short-term bDFS and limited late toxicity. These outcomes will continue to be followed with the goals of confirming equivalence or superiority to alternative radiation therapy treatment approaches.

Conservative management of low-risk prostate cancer among young versus older men in the United States: Trends and outcomes from a novel national database.

Management for men aged ≤55years with low-risk prostate cancer (LRPC) is debated given quality-of-life implications with definitive treatment versus the potential missed opportunity for cure with conservative management. The objective of this study was to define rates of conservative management for LRPC and associated short-term outcomes in young versus older men in the United States. The nonpublic Surveillance, Epidemiology, and End Results Prostate with Active Surveillance/Watchful Waiting (AS/WW) Database identified 50,302 men who were diagnosed with LRPC from 2010 through 2015. AS/WW rates in the United States were stratified by age (≤55 vs ≥56years). Prostate cancer-specific mortality and overall mortality were defined by initial management type (AS/WW vs definitive treatment [referent]) and age. AS/WW utilization increased from 8.61% (2010) to 34.56% (2015) among men aged ≤55years (P for trend <0.001) and from 15.99% to 43.81% among men aged ≥56years (P for trend <.001). Among patients who had ≤2 positive biopsy cores, AS/WW rates increased from 12.90% to 48.78% for men aged ≤55years and from 21.85% to 58.01% for men aged ≥56years. Among patients who had ≥3 positive biopsy cores, AS/WW rates increased from 3.89% to 22.45% for men aged ≤55years and from 10.05% to 28.49% for men aged ≥56years (all P for trend <.001). Five-year prostate cancer-specific mortality rates were <0.30% across age and initial management type subgroups. AS/WW rates quadrupled for patients aged ≤55years from 2010 to 2015, with favorable short-term outcomes. These findings demonstrate the short-term safety and increasing acceptance of AS/WW for both younger and older patients. However, there are still higher absolute rates of AS/WW in older patients (P<.001), suggesting some national ambivalence toward AS/WW in younger patients.

Trends in Conservative Management for Low-risk Prostate Cancer in a Population-based Cohort of Australian Men Diagnosed Between 2009 and 2016

Conservative management, specifically with active surveillance (AS), has emerged as the preferred approach for low-risk prostate cancer (LRPC). We evaluated the trend for conservative management (ie, no active treatment within 12mo of diagnosis) for LRPC in an Australian population-based cohort of men captured in the Prostate Cancer Outcomes Registry Victoria (PCOR-Vic). Of the 3201 men diagnosed with LRPC between January 2009 and December 2016, 60% (1928/3201) had conservative management, and 52% (1664/3201) were documented to be on AS. There was an increase in conservative management from 52% in 2009 to 73% in 2016 (p<0.001), largely attributable to an increase in AS from 33% in 2009 to 67% in 2016 (p<0.001). When stratified by age group, the increase in conservative management was more pronounced among younger patients: from 37% to 66% for men aged <60yr versus from 72% to 86% for men aged ≥70yr. In multivariable analyses, increasing age, lower prostate-specific antigen and clinical category, lower socioeconomic status, and being diagnosed in public metropolitan institutions were all independently associated with a greater likelihood of conservative management. Identification of sociodemographic and institutional variations in practice allows for targeted strategies to improve management for men with LRPC. Patient summaryWe looked at the uptake of conservative management (no active treatment within 12 mo of diagnosis) over time in an Australian population-based cohort of men with low-risk prostate cancer. The proportion of men with low-risk prostate cancer managed conservatively increased from 52% in 2009 to 73% in 2016. The increase in the uptake of conservative management for low-risk prostate cancer in Australia is concordant with international guidelines and other international population-based studies.

Management of low-risk prostate cancer in a population-based cohort of Australian men between 2008 and 2016.

13 Background: The aim of this study is to evaluate the practice pattern of management of NCCN low-risk prostate cancer (LRPC) in a population-based cohort of Australian men. Methods: This is prospective cohort of men captured in Prostate Cancer Outcomes Registry Victoria (PCOR-Vic), who were diagnosed with LRPC between Aug 2008 and Dec 2016. Conservative management was defined as no active treatment (surgery, radiotherapy, or other local therapy) within 12-month of LRPC diagnosis. Chi-squared test for trend was used to evaluate change in practice over time. Multivariate logistics regressions were used to patient-, tumour- and institutional factors influencing the likelihood of conservative management for LRPC. Results: A total of 3238 men with LRPC were identified in the PCOR-Vic database. The median age was 62.6 (range:37-94). The median PSA level was 5.1ng/mL (range: 0.01-9.96). Overall, 1934 (60%) had conservative management, of which 1668 (86%) were documented as being on active surveillance. Of the 1304 (40%) men who active treatment within 12-month of diagnosis, 977 (30%) had surgeries, 289 (9%) had radiotherapy, and 38 (1%) had other local treatment. Overall, there is increasing trend in conservative management for LRPC from 52% in 2009 to 73% in 2016 (P&lt;0.001). In multivariate analyses, age, PSA, clinical stage, institutions and year of diagnosis were all independently associated with conservative management. Men diagnosed in private and regional centres were 26% (95%CI=0.63-0.88, P=0.001) and 40% (95% CI=0.51-0.72, P&lt;0.001) less likely to have conservative management for LRPC. Conclusions: This is the largest Australian series on management of LRPC to date. We observe increasing use of conservative management for LRPC over time, however, there is large institutional variations in care with men diagnosed in private and regional centres more likely to have active local management for LRPC.