AUA 2010 - Prostate Cancer: Active Surveillance - SUO Meeting - Session Highlights

UroToday | 05.29.2010

The pro and con positions were presented in this panel discussion.

H. Ballantine Carter, MD, Johns Hopkins Hospital School of Medicine, presented in favor of active surveillance. Dr. Carter stated that Active Surveillance (AS) is one strategy to avoid overtreatment of men with prostate cancer (CaP).

AS requires careful selection of men at low risk of harm from CaP without undergoing treatment. It involves careful monitoring of these men and intervention as indicated. Many men over age 70 are over-treated, he said. He defined for whom AS is appropriate; stage T1c/T2a, PSA <10ng/ml, PSAD <0.15, Gleason score ≤6 with <3 cores involved with cancer in less than 50% of each core. This subset of men does differ from the general group of low-risk CaP patients, as the latter has a 1.6-fold increased risk of high risk disease.

However, like treatment, AS is not risk free. What is the risk of CaP progression during AS and does it impact overall health outcomes, he asked? A missed high-risk grade CaP poses the major risk for men on AS. The differences are only seen in men with AS biopsy upgrading to Gleason score 7. At 5 and 10 years, 82% and 66% of men on AS remain with no Gleason score >7, respectively. Overall, this upgrading is 30% at 10 years and 13% of the overall population would be found to have Gleason score 4+3.

The very low risk patient should consider AS since overall health outcomes are not likely improved with surgery when compared with AS, he concluded.

Taking the opposing opinion was William Catalona, MD, Northwestern University Feinberg School of Medicine. Dr. Catalona believes that a very low risk man should be treated with a radical prostatectomy.

The high incidence to mortality ratio is acceptable if accompanied by a decrease in mortality rates. The number needed to treat in order to save one life is considered to be 48:1 based upon the ERSPC data. However, longer followup and correction for contamination will bring this number down by up to 50%. In an Irish study, the ratio was much lower at 15:1. He said that not every tumor that appears to be low-risk grows slowly and there was a 3-fold increase in CaP progression and death after 15 years of followup.

In the Scandinavian Trial of Watchful Waiting (WW) vs. Radical Prostatectomy (RP), there was a lower rate of metastases if treated with RP vs. WW.

In AS, the good news comes early and the bad news comes late. The good news is that few patients require treatment and most receiving late treatment do well. However, the bad news is the undergrading and understaging.

In the Toronto trial, 50% of delayed treatment patients had PSA failure, which is concerning, he stated. In Dr. Carter’s own series, 35% of men who had delayed RP had pT3 disease. We cannot identify the very low-risk patients who harbor aggressive tumors.

Using the Epstein criteria to identify insignificant CaP is inaccurate in one-third of cases. Early treatment will avoid numerous biopsies and have a better surgical outcome.

Moderated by Ian Thompson, MD (University of Texas Health Science Center) at the Society of Urologic Oncology Meeting held concurrently with the American Urological Association (AUA) Annual Meeting - May 29 - June 3, 2010 - Moscone Center, San Francisco, CA USA

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