Surgical management after active surveillance for low‐risk prostate cancer: pathological outcomes compared with men undergoing immediate treatment

Abstract

Study Type – Therapy (case control) Level of Evidence 3b What's known on the subject? and What does the study add? The risks of delayed radical prostatectomy for men who progress on active surveillance are largely unknown. Two series have reported that prostatectomy after active surveillance has similar results to immediate therapy. Our data add to this growing body of evidence that appropriately selected men with prostate cancer can undergo active surveillance with delayed prostatectomy without added risk of missing an opportunity for cure as the majority of tumours remain organ confined. OBJECTIVE • To compare the pathological outcomes of men undergoing radical prostatectomy (RP) after a period of active surveillance (AS) with those of a similar risk group undergoing immediate surgery. PATIENTS AND METHODS • We identified men through our institutional database who underwent RP within 6 months of diagnosis or after a period of AS. The primary outcome of the present study was Gleason upgrade to ≥7 after prostatectomy. • Pathological stage and positive surgical margin rate were assessed as secondary outcomes. Binomial logistic regression models were used to determine associations of treatment subgroups with pathological upgrade, upstage and positive margins. RESULTS • Thirty‐three men with initially low‐risk cancer features underwent RP after a median (range) of 18 (7–76) months of AS. A total of 278 men with low‐risk disease features underwent immediate RP within 6 months of diagnosis. Rates of Gleason upgrading to ≥7, pathological category pT3 and positive surgical margins did not differ significantly from the immediate RP group. • On multivariate analysis of low‐risk patients, adjusting for baseline pathological features, treatment group (AS followed by prostatectomy vs immediate prostatectomy) was not associated with Gleason upgrading (odds ratio, OR, 0.35; 95% CI, 0.12–1.04), non‐organ‐confined disease (OR, 1.67; 95% CI, 0.32–8.65) or positive surgical margins at prostatectomy (OR, 0.95; 95% CI, 0.16–5.76). CONCLUSION • The present analysis did not show an association between RP after a period of AS and adverse pathological features for men with low‐risk disease.

Active surveillance for the management of localized prostate cancer: Guideline recommendations

“…Eight non-comparative studies of low-risk patients undergoing active surveillance reported prostate cancer survival rates of 100% [5][6][7][8][9][10][11][12] and another two non-comparative studies reported high prostate cancer survival rates of 97% 13 98%, respectively. 14 Studies comparing immediate RP with delayed RP in patients undergoing AS detected no significant differences in biochemical recurrence rate, positive surgical margins, extraprostatic extension, [15][16][17] and risk of incurable cancer. [18][19] Clinical outcomes following immediate or delayed surgical treatment did not differ, suggesting that there is acceptably low risk associated with undergoing AS and delaying definitive therapy.…”

“…Six studies conducted PSA testing every 3 months, 5,8,[14][15][16][17] 3 studies conducted PSA tests every 3 months for 1 year, 6,9,28 and 8 studies conducted PSA tests every 3 months for 2 years. 11,13,19,20,[29][30][31][32] For studies following patients beyond 2 years, PSA testing was conducted every 6 months after the second year.…”

Active Surveillance for Prostate Cancer: A Systematic Review of the Literature

“…Several papers have described the outcomes from delayed intervention after a period of AS [48][49][50]. In one of the earliest reports from Johns Hopkins, rates of ''noncurable'' PCa after delayed intervention were low (23%) and did not differ from men undergoing immediate surgery [50].…”

Limiting overdiagnosis of low-risk prostate cancer through an evaluation of the predictive value of transrectal and power Doppler ultrasonography

“…Studies on cohorts of patients with clinically localized and non-treated prostate cancer have shown that overall survival is excellent in patients with a Gleason score of less than 7. According to Dall'Era, there is no significant prognostic difference between the low-risk patients immediately treated and those who benefited from active surveillance before surgery [28].…”