Prostate cancer active surveillance criteria needs expansion

About a third of prostate cancer patients who met strict criteria for active surveillance (AS) had adverse pathology at radical prostatectomy (RP), according a study published in the February issue of the Journal of Urology. The authors suggested that inclusion criteria for active surveillance should include PSA density and cancer extent on biopsy.

Previous studies have discovered that approximately one-third of prostate cancer patients with a Gleason score of six are upgraded at radical prostatectomy. “This issue is particularly germane to men with presumed low risk prostate cancer considering active surveillance, for whom accurate pretreatment risk stratification is paramount,” wrote lead author Annelies Vellekoop, MD, of New York University and Manhattan Veteran Affairs Medical Center, and colleagues.

Vellekoop and co-authors investigated trends and predictors of upgrading and up staging among 4,500 Swedish men with Gleason six prostate cancer who were potential candidates for AS in their study. Of this population, 2,205 men had data on the extent of prostate cancer within biopsy core. The researchers also studied total biopsy length, extent of cancer, and ratio of cancer extent in this group. The frequency of adverse pathology was then examined and logistic regression was utilized to analyze predictors in the study’s population and in possible candidates for active surveillance using six AS protocols.  

Results revealed that men treated with RP were significantly younger, had smaller prostates, lower prostate specific antigen (PSA), fewer comorbidities, more sampled biopsy cores, and more positive cores. The median total biopsy length was 140 mm and the extent of cancer was six mm. Eighty-six percent of the men had a ratio of cancer extent that was less than 15 percent. Half of the study group (2,235 patients) had adverse pathology at RP. Predictors of adverse pathology were older age, higher PSA, PSA density greater than 0.15 ng/ml/cm3 and palpable disease and extent of cancer greater than four mm on biopsy. Adverse pathology was evident in 33 to 45 percent of the men who met the study inclusion criteria of six different AS protocols.

“These results have important implications for the optimization of AS in the future,” wrote Vellekoop and colleagues. “Most AS programs consider PSA and clinical stage for patient selection, and we confirmed that there is a greater risk of misclassification in men with a higher PSA and/or palpable disease. Despite recent controversy over the usefulness of digital rectal examination in PCa screening, these results suggest that it continues to have a role in staging.”