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From the Spring 2018 Quest
With active surveillance, men choose to delay or avoid having radical treatment for their prostate cancer, such as surgery or radiation, while monitoring their disease through repeated biopsies, digital rectal exams, and PSA tests. Ideally, active surveillance patients avoid the potential side effects associated with treatment for slow- growing tumors that are unlikely to harm them.

Ongoing research continues to assess the criteria used to select patients for active surveillance. Clinical guidelines currently recommend active surveillance for men diagnosed with very low-risk and low-risk prostate cancer. Guidelines also state that men with low-volume intermediate risk disease can consider active surveillance, although this is controversial-and results from a recent study indicated that men in this group may not be suitable candidates for active surveillance.

The goal of the new study was to evaluate the risk categories that determine if a patient is an appropriate candidate for active surveillance. The study included 6,721 men who underwent radical prostatectomy at Johns Hopkins Hospital. Patients in the low-volume intermediate-risk category had Gleason scores 3+4=7, PSA less than 20 ng/mL, and cancer in 1-2 of their cores.

Comparing adverse findings

The authors compared pathologic findings for the patients in each group after they had surgery. Patients with low-volume intermediate-risk disease had much higher rates of adverse findings after surgery. This means their tumors actually had features of aggressive disease that were not found at diagnosis, but were later discovered at the time of surgery. Nearly 25% of patients diagnosed with low-volume intermediate-risk disease had adverse findings, compared to only 5.8% of low- risk patients and 4.7% of very low-risk patients.

Among the patients with low- volume intermediate-risk tumors who had adverse findings at surgery, 94% were upgraded to at least Gleason 4+3=7 disease. Tumors with a Gleason score of 3+4=7 generally indicate patients have a good outlook, while tumors with a Gleason score of 4+3=7 are more likely to grow and spread. If these patients had elected active surveillance, they would have had a higher risk of the cancer spreading.

The future of selecting patients for active surveillance

The results of this study further support the need to improve ways to select patients for active surveillance. Dr. Catalona and his collaborators' SPORE research project aims to pinpoint which genetic mutations indicate if a patient is a good candidate for active surveillance or not. The research team hopes that in the future, the results from this project will enable clinicians to utilize genetic testing when counseling patients about their treatment options for prostate cancer.

JAMA Oncol. 2018 Jan 1;4(1):89-92. doi: 10.1001/jamaoncol.2017.1879.

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