Prostate Cancer: Choosing Candidates for Active Surveillance

Hello. I am Dr. Gerald Chodak for Medscape. This week I want to talk about the criteria being used to select men for active surveillance for prostate cancer.

Vellekoop and coworkers ^[1] looked at the results from the National Prostate Cancer Registry in Sweden and found about 4500 men who were thought to be good candidates for active surveillance yet who underwent radical prostatectomy. The authors then compared pathology results from the surgeries with the preoperative information, such as the Gleason scores, the prostate-specific antigen (PSA) levels, the total amount of cancer on the biopsy cores, and the PSA density. Next, they looked at 6 protocols that are being used for active surveillance around the world, and they found that the ultimate, unfavorable pathology was detected in 33%-45% of the patients. On the basis of their analysis, this group suggests that a lot of the men who are thought to be good candidates for active surveillance will probably have adverse pathology should they undergo radical prostatectomy.

What does this mean? Given this analysis, it would mean that many of the men who were thought to be good candidates for active surveillance are really not good candidates. That conclusion is a challenge to some of the other information that is being disseminated around the world.

Several things are worth commenting on. The authors' definition of adverse pathology was either upgrading to a Gleason score of 7 or finding extracapsular (pT3) disease. The problem with those criteria is that we know they do not always turn out to be dangerous. In fact, a high percentage of men do not get into trouble with either Gleason 7 cancer or pT3 disease. If we look at the results from Klotz and coworkers, ^[2] who have the most liberal finding, their prostate cancer mortality at 10 years was only about 3%. Lu-Yao and colleagues ^[3] evaluated Medicare patients in the United States who had active surveillance and watchful waiting, and found that the prostate cancer mortality at the end of 10 years was only 6%, even though we know that many of those men would have had unfavorable pathology if they had undergone surgery.

I think this new study ^[1] raises undue concerns. The authors believe that we should use more stringent criteria to reduce the chance of finding unfavorable pathology. That would include using criteria of having l < 4 mm of cancer and a PSA density < 0.15, but I personally believe that, based on the analyses in other studies that have been published, this is too strict. Trying to use the pathology results to make determinations about whether we are using the right criteria is not an adequate way to make this evaluation. We really should rely on cancer mortality statistics from studies such as those by Peter Albertson, ^[4] Laurie Klotz, ^[2] and Lu-Yao. ^[3]

When you look at mortality, having unfavorable pathology does not necessarily translate into bad outcomes. I believe that we have to be careful that we do not tell a lot of men that they should have surgery rather than active surveillance when active surveillance is probably the right thing for them to do. I look forward to your comments. Thank you.

Fonte: https://www.medscape.com