Long-term active surveillance safe, viable option for certain men with prostate cancer
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Metastasis and prostate cancer-specific death appeared rare among men with low-risk and carefully selected intermediate-risk prostate cancer undergoing long-term active surveillance, according to study data published in Journal of Urology.
However, higher Gleason grade, PSA velocity and characteristics on imaging were associated with a higher risk for metastasis. Thus, these factors should be taken into account when selecting, following and counseling men for active surveillance, researchers noted.
“There is relatively little known about long-term outcomes on active surveillance. Our study addresses this and gives assurance to many who might be eligible but fear the risk for developing metastases on active surveillance,” Peter Carroll, MD, MPH, in the department of urology at University of California, San Francisco, told Healio. “When done well, active surveillance appears safe and should be considered and discussed among those with very low-, low- and some patients with intermediate-grade cancers. New technology and MRI, as well as genomic biomarkers, appear to make active surveillance safer.”
Carroll and colleagues assessed the long-term outcomes of 1,450 men (median age at diagnosis, 62 years) diagnosed with low- or intermediate-risk prostate cancer (median PSA at biopsy, 5.4 ng/ml; median PSA density, 0.13 ng/ml/cm³) enrolled on active surveillance between 1990 and 2018. Researchers additionally sought to identify potential prognostic factors that may predict metastasis risk.
Researchers categorized the men into three groups by diagnostic grade and PSA density: diagnostic grade group (GG) 1 with PSA density less than 0.15 ng/ml/cm3 (57%), diagnostic GG1 with PSA density of 0.15 ng/ml/cm3 or greater (32%), and GG2 with any PSA density (10%).
Metastatic prostate cancer detected on imaging or at prostatectomy served as the primary outcome. Researchers also examined upgrade at surveillance biopsy, receipt of active treatment, and overall and prostate cancer-specific survival.
At median follow-up of 77 months, the 7-year metastasis-free survival rate was 99% and the 7-year prostate cancer-specific survival rate was greater than 99%.
Fifteen men developed metastases at a median of 62 months, of which 69% were confined to the lymph nodes.
Men with diagnostic GG2 disease had poorer metastasis-free survival than men with diagnostic GG1 disease (HR = 19.8; 95% CI, 4.9-79.3). Other factors associated with a higher risk for metastases included PSA velocity (HR = 1.4; 95% CI, 1.1-1.7) and lesions with a score of 4 to 5 per Prostate Imaging Reporting and Data System criteria on multiparametric MRI (HR = 8.5; 95% CI, 2.2-33.1).
At a median of 84 months, 64 men died, four of which were prostate cancer-associated deaths. Seven-year OS was 97% for all patients.
“There are two important next steps,” Carroll said. “First, active surveillance should be tailored to patients’ risk for progression, it should be less burdensome in those at low risk and unnecessary biopsies should be avoided. Second, we should assess if we can expand the eligibility to those with intermediate-risk cancers enabled by advanced imaging, assessment of Gleason grade subtype and genomics.”
For more information:
Peter Carroll, MD, MPH, can be reached at University of California, San Francisco, 550 16th St., San Francisco, CA 94143; email: peter.carroll@ucsf.edu.
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