Striking the Balance in Prostate Cancer: Active Surveillance Versus Disease Progression

The debate over when is cancer at a stage where wait-and-watch takes precedence over active treatment doesn’t seem to have a solution. Monitoring the tumor rather than overtreating can prevent harmful and unnecessary effects on the patient’s quality of life. A new study published in The Journal of Urology has found that active surveillance in prostate cancer patients who might have a low-grade disease has the possibility of disease progression in only a small number of patients.

Expression level of prostate specific antigen (PSA) remains the standard measure of a patient’s risk for prostate cancer progression. Low-risk prostate cancer is characterized by a Gleason Score (GS) of 6 or less, with PSA not exceeding 10 ng/ml.

“This is a detailed analysis of thirty patients initially treated with surveillance for what was thought to be favorable disease, but which eventually progressed to metastatic disease,” said Laurence Klotz, MD, FRCS(C), in a statement. He is professor of Surgery at the University of Toronto and the study’s lead author. “We previously reported on five such patients. The current report represents a considerably larger group with longer follow-up, which presented an opportunity for risk analysis.”

In their prospective trial, initiated in 1995, the researchers at the Sunnybrook Health Sciences Center at the University of Toronto followed Of the 980 patients analyzed, 211 (21.5%) were classified as intermediate risk, 109 (11.1%) had baseline PSA greater than 10 ng/ml and 133 (13.6%) had GS 7 disease. The investigators analyzed the clinical and pathological correlates of surveillance in patients who eventually experienced metastasis. The median follow-up was 6.3 years (range 0.2 to 20.2).

The researchers confirmed that active surveillance appears safe in patients at low risk and in select patients at intermediate risk, particularly those with GS 6 and PSA greater than 10 ng/ml. Metastasis developed in 3% (30 of 980) of patients. Of the 980 patients, 211 were classified at intermediate risk. Fifteen died of prostate cancer and 4 died of another cause while 11 were living with metastases at the close of the study. Bone metastases developed in 18 patients (60%) and lymph node metastases in 13 (43%). The risk of metastasis increased to 10% (13 of 133) in patients with GS 7 disease.

“The presence of Gleason pattern 4 on diagnostic biopsy conferred a threefold to fourfold increased risk of metastatic disease. Such patients should be offered surveillance with caution. Further evaluation with magnetic resonance imaging and/or genetic biomarkers should be strongly encouraged if surveillance is elected as an option in these patients,” noted Klotz.

Source: Science Daily