Presentation Authors: Edouard Nicaise*, Alice Yu, Boston, MA, Andrew Gusev, Timothy Baloda, Worcester, MA, David Kuppermann, Anthony Zietman, Mark Preston, Douglas Dahl, Michael Blute, Adam Feldman, Boston, MA
Introduction: Active surveillance (AS) has become an accepted management strategy for very low risk, low risk, and select cases of favorable intermediate risk localized prostate cancer. Long term data will be critical to continued understanding of which patients are suitable for this strategy and when patients should transition to treatment. We update and investigate long-term follow up in our active surveillance cohort.
Methods: Under IRB approved protocol, a retrospective cohort study of 1294 men diagnosed with localized prostate cancer was performed at a single tertiary-care center from 1996-2016. In 2008 our group agreed on the following AS guidelines: Gleason â‰¤ 6 (Gleason 7 in select patients with low volume), â‰¤3/12 cores positive with â‰¤20% in each core, and PSA < 10. Our follow-up protocol includes: PSA/DRE every 4-6 months x 3 years, then annually. Mandatory confirmatory 12 core biopsy is performed at 12-18 months with subsequent biopsies at the discretion of the treating physician. In 2014 multiparametric MRI and fusion biopsy became integrated into our practice. Survival analyses were conducted using the Kaplan-Meier method.
Results: The study cohort consisted of 1294 men with a median age at diagnosis of 66.0 (IQR, 60.0-71.0 years). Median follow-up was 6.5 years (Range, 0.1-22.1 years). The median PSA at diagnosis was 5.1 ng/mL (IQR, 4.0-6.9 ng/mL) with 91% having a PSA < 10 ng/mL. Overall, 97.0% (1256/1294) of patients were Gleason 6 or lower, and 2.9% (38/1294) were Gleason 7. 90.8% (1176/1294) were stage T1c. Freedom from intervention was 86% at 5 years, 52% at 10 years, 46.1% at 15 years. 496 patients required treatment during the course of surveillance. Reasons for intervention included: 65.9% (327/496) pathologic progression, 13.9% (69/496) PSA progression, 9.9% (49/496) patient preference, 2.2% (11/496) DRE progression, 2.0% (10/496) metastatic disease. Of patients who were treated, 216 (43.5%) received radiation, 191 (22.4%) received surgery, 54 (10.8%) received brachytherapy, 33 (6.6%) received hormonal therapy, 2 (0.4%) received unknown treatment. On pathologic review after radical prostatectomy, 32/496 (16.8%) patients were pathologic stage T3. Cancer-specific survival was 99.8% at 5 years, 98.6% at 10 years, 94.5% at 15 years. Overall survival was 97.0% at 5 years, 85% at 10 years, 59.4% at 15 years.
Conclusions: Approximately half of men on AS are treated by 10 years with the most common reason being pathologic progression. Active surveillance appears to remain a safe and established management strategy without a negative impact on the patient&[prime]s ultimate care.