Is Active Surveillance Beneficial for Patients With Intermediate-Risk Prostate Cancer?

Recent research explored the potential of a subset of patients with intermediate-risk prostate cancer likely to benefit from active surveillance.

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Active surveillance is currently recommended for patients with very-low risk and low-risk prostate cancer. Recent clinical guidelines suggest that active surveillance may be considered for some men with low-volume intermediate-risk disease. However, this addition to the guideline has been met with some resistance among clinicians. Research is needed to determine whether a subset of men exists with Gleason 3 + 4 = 7 intermediate-risk prostate cancer on biopsy with favorable characteristics to minimize risk of adverse pathologic findings at surgery.

Hiten D Patel, MD, MPH, Johns Hopkins University, and colleagues conducted a retrospective study to compare rates of adverse pathologic findings among very-low risk, low-risk, and low-volume intermediate-risk patients choosing immediate radical prostatectomy and to determine whether a favorable intermediate-risk group exists. Researchers chose a cohort of 6721 patients with either very-low, low-risk, or low-volume intermediate-risk disease (n = 1264, 4849, and 608, respectively). Proportions of patients demonstrating at least Gleason 3 + 4 = 7 disease and other pathologic features were compared by risk group.

The study was published in JAMA Oncology (online July 13, 2017; doi:10.1001/jamaoncol.2017.1879).

Results of the analysis showed the rate of adverse pathologic findings was significantly higher in low-volume intermediate-risk disease (n = 150 patients, 24.7%) compared with low-risk (n = 280, 5.8%), as well as in low-volume intermediate-risk disease compared with very-low risk disease (n = 60, 4.7%). Patients with low-volume intermediate-risk prostate cancer had a 4.5-fold greater risk of adverse pathologic findings compared with those who had low-risk disease and a 5.1-fold greater risk compared with those who had very-low risk disease.

Researchers reported no preoperative clinical or pathologic criteria that could determine a subgroup of patients with low-volume intermediate-risk disease with rates of adverse pathologic findings comparable to those of the very-low risk and low-risk cohorts.

Multivariate analysis showed that while PSA density predicted adverse pathologic findings, Gleason score had the greatest impact.

“Our observations suggest use of active surveillance may place similar men with Gleason 3 + 4 = 7 cancer at risk of adverse outcomes that could have potentially been avoided with immediate intervention,” the authors wrote. “This study could have important implications for men with low-volume intermediate-risk prostate cancer electing active surveillance, and further study is clearly needed.”—Zachary Bessette