PCa Active Surveillance Safe, Effective for Younger Patients
A majority of active surveillance patients under age 60 did not progress to definitive prostate cancer treatment.
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BOSTON – Men enrolled in active surveillance (AS) for low-risk prostate cancer (PCa) before age 60 appear to fare no worse than typically older men on AS, researchers confirmed at the American Urological Association meeting.
“Younger men are often counseled toward definitive treatment due to their longer life expectancy, fewer co-morbidities, and the perceived likelihood of ultimately undergoing treatment,” lead investigator Keyan Salari, MD, PhD, said. When it comes to AS eligibility for PCa, however, most institutions do not have strict criteria on patient age, he added.
Of 2152 AS patients from Massachusetts General Hospital in Boston or Sunnybrook Health Sciences Centre in Toronto placed on AS from 1990-2016, 432 patients were younger than 60, he reported. At diagnosis, the median age of the younger group was 55 years and PSA level was 4.6 ng/mL with only 11 men displaying values of 10 ng/mL or higher. Most were diagnosed with Gleason score 6 or lower disease (97.7%) and clinical stage T1 (91.9%). For 92.8% of patients, a third or fewer biopsy cores were positive; for three-quarters (77.2%), 20% or less of any single core showed cancer.
During a median 5 years of follow up, 84.3% of younger patients had repeat prostate biopsy. Two-thirds (62.6%) were found to have PCa, 24.5% benign tumor, 7.7% prostatic intraepithelial neoplasia, and 5.2% atypia.
A majority of younger patients remained free from PCa treatment: 74.3% at 5 years and 55.4% at 10 years, according to Kaplan Meier estimates. For the entire cohort of men on AS, these rates were comparable at 77% at 5 years and 62% at 10 years.
Results showed that 30.3% of younger patients chose definitive treatment due to pathologic progression (64.1%), rising PSA (18.3%), individual preference (11.5%), volume progression (3.1%), or other reasons (3.1%). Among patients who selected treatment, 62.6% underwent radical prostatectomy (RP), 13.0% high-intensity focused ultrasound, 12.2% external beam radiation, 10.7% brachytherapy, and 1.5% another therapy.
Pathology staging results showed that 88.2% of surgery patients had T2 and 11.8% had T3 disease. Of the 5 patients with metastasis, 2 had positive lymph nodes at RP and 3 had distant metastasis. Metastasis-free survival rates were 99.7% and 97.5% at 5 and 10 years, respectively, according to Kaplan-Meier analysis. No patient died of PCa.
“Active surveillance is a reasonable option for carefully selected men under 60 with low-risk prostate cancer,” Dr Salari concluded. It spares appropriately selected younger men from immediate treatment without closing the window on timely intervention if needed. Multiparametric magnetic resonance imaging shows promise in helping to select appropriate AS candidates, he said.
Unfavorable measures of tumor volume predicted eventual active treatment of PCa: elevated PSA density (0.15 or above), percentage of positive cores (above 33%), and percentage of core involved with tumor (above 20%).
Salari K, Kuppermann D, Preston M, et al. Active surveillance for low-risk prostate cancer in men under 60 years of age. [abstract] J Urol 2017;197(4S):e1051-e1052. Oral presentation at the American Urological Association 2017 annual meeting in Boston on May 15, 2017. Abstract PD55-03.