Active surveillance for prostate cancer: a systematic review of contemporary worldwide practices

Abstract

In the last decade, active surveillance (AS) has emerged as an acceptable choice for low-risk prostate cancer (PC), however there is discordance amongst large AS cohort studies with respect to entry and monitoring protocols. We systematically reviewed worldwide AS practices in studies reporting ≥5 years follow-up. We searched PubMed and Medline 2000-now and identified 13 AS cohorts. Three key areas were identified: (I) patient selection; (II) monitoring protocols; (III) triggers for intervention—(I) all studies defined clinically localised PC diagnosis as T2b disease or less and most agreed on prostate-specific antigen (PSA) threshold (<10 µg/L) and Gleason score threshold (3+3). Inconsistency was most notable regarding pathologic factors (e.g., number of positive cores); (II) all agreed on PSA surveillance as crucial for monitoring, and most agreed that confirmatory biopsy was required within 12 months of initiation. No consensus was reached on optimal timing of digital rectal examination (DRE), general health assessment or re-biopsy strategies thereafter; (III) there was no universal agreement for intervention triggers, although Gleason score, number or percentage of positive cancer cores, maximum cancer length (MCL) and PSA doubling time were used by several studies. Some also used imaging or re-biopsy. Despite consistent high progression-free/cancer-free survival and conversion-to-treatment rates, heterogeneity exists amongst these large AS cohorts. Combining existing evidence and gathering more long-term evidence [e.g., the Movember’s Global AS database or additional information on use of magnetic resonance imaging (MRI)] is needed to derive a broadly supported guideline to reduce variation in clinical practice.

A systematic review of the unmet supportive care needs of men on active surveillance for prostate cancer

“…Many of these issues have also been identified in previous systematic reviews of unmet needs in PCa26,27 patients who have undergone treatment.Understanding men's unmet needs during AS may assist researchers and health professionals in empowering men to adhere until treatment is medically necessary. With approximately 10% to 20% of men who begin AS discontinuing without disease progression[18][19][20] , interventions that consider men's experiences and unmet needs are required.…”

Use of multiparametric magnetic resonance imaging in prostate cancer active surveillance

“…Data from the University of Toronto prospective AS cohort, which includes some men with intermediate‐risk features, show excellent results, but found that the 15‐year prostate cancer metastasis rate was 3.7 times higher with intermediate‐risk men at baseline, suggesting that such men need to be selected and followed carefully . Results from multiple AS studies with inclusion criteria established prior to the widespread availability of mpMRI or tissue based biomarkers, demonstrate excellent results: this must be appreciated when considering adding any new technology with additional cost to patient care . There is room for improvement, however, especially given relatively high attrition and treatment rates over time .…”

“…Results from multiple AS studies with inclusion criteria established prior to the widespread availability of mpMRI or tissue based biomarkers, demonstrate excellent results: this must be appreciated when considering adding any new technology with additional cost to patient care [21]. There is room for improvement, however, especially given relatively high attrition and treatment rates over time [22].…”

An overview of translational prostate cancer cohorts for prognostic and predictive studies

“…Of course, this is only permissible in tumours with a very low risk of progression, according to conventional parameters. Most AS regimens include patients with low PSA levels (<10 ng/ml), Gleason score 6 and limited tumour extent on biopsy (one to two cores) . Therefore, biomarkers that broaden these inclusion criteria are highly sought‐after.…”

“…Most AS regimens include patients with low PSA levels (<10 ng/ml), Gleason score 6 and limited tumour extent on biopsy (one to two cores). 16,17 Therefore, biomarkers that broaden these inclusion criteria are highly soughtafter. Currently, it is unclear if tissue-based molecular testing or novel radiological techniques such as multiparametric MRI will be taking the lead in guiding therapy.…”