Carl Welty

© 2015 European Association of Urology. Background: Biopsy progression on active surveillance for prostate cancer often reflects failure of the initial biopsy to detect cancer present at enrollment. The risks for delayed treatment among men who progress on AS are not well defined. Objective: To report outcomes for men who underwent surgery after AS compared to men who underwent immediate surgery and the influence of selection bias on this outcome. Design, setting, and participants: AS-eligible men who underwent radical prostatectomy after a median of 20 mo of AS were compared to ASE men who underwent RP within 6 mo of diagnosis. A subset of men on AS who underwent RP after upgrade to Gleason 3 + 4 was compared to matched controls with similar pretreatment biopsy features who underwent immediate RP. Outcome measurement and statistical analysis: Rates of adverse pathology were examined. Logistic regression was used to determine associations between treatment subgroup and adverse pathology. Results and limitations: Of 157 ASE men who underwent delayed RP after AS, 54 were upgraded to Gleason 3 + 4 before surgery. ASE men who underwent immediate RP had lower probability of adverse pathology than ASE men who underwent delayed RP. The rate of adverse pathology did not differ between immediate and delayed RP patients matched for pretreatment characteristics. The observational design of this study is its main limitation. Conclusions: When compared to men with similar pretreatment biopsy features, those who underwent delayed RP were not at higher risk of adverse pathology. Patient summary: The oncologic safety of delayed treatment when indicated for men enrolled in active surveillance for prostate cancer is important. We found that men who underwent delayed surgery had similar outcomes to men who underwent immediate prostatectomy. In a large active surveillance cohort, men with low-risk prostate cancer who underwent prostatectomy after upgrading while on active surveillance had similar pathologic outcomes to men with similar preoperative risk features who underwent immediate prostatectomy.

Purpose: Active surveillance to manage prostate cancer provides an alternative to immediate treatment in men with low risk prostate cancer. We report updated outcomes from a long-standing active surveillance cohort and factors associated with reclassification. Materials and Methods: We retrospectively reviewed data on all men enrolled in the active surveillance cohort at our institution with at least 6 months of followup between 1990 and 2013. Surveillance consisted of quarterly prostate specific antigen testing, repeat imaging with transrectal ultrasound at provider discretion and periodic repeat prostate biopsies. Factors associated with repeat biopsy reclassification and local treatment were determined by multivariate Cox proportional hazards regression. We also analyzed the association of prostate specific antigen density and outcomes stratified by prostate size. Results: A total of 810 men who consented to participate in the research cohort were followed on active surveillance for a median of 60 months. Of these men 556 met strict criteria for active surveillance. Five-year overall survival was 98%, treatment-free survival was 60% and biopsy reclassification-free survival was 40%. There were no prostate cancer related deaths. On multivariate analysis prostate specific antigen density was positively associated with the risk of biopsy reclassification and treatment while the number of biopsies and time between biopsies were inversely associated with the 2 outcomes. When stratified by prostate volume, prostate specific antigen density remained significantly associated with biopsy reclassification for all strata but prostate specific antigen density was only significantly associated with treatment in men with a smaller prostate. Conclusions: Significant prostate cancer related morbidity and mortality remained rare at intermediate followup. Prostate specific antigen density was independently associated with biopsy reclassification and treatment while on active surveillance.

© 2015 American Urological Association Education and Research, Inc. Purpose: We describe the outcomes of patients with low risk localized prostate cancer who were upgraded on a surveillance biopsy while on active surveillance and evaluated whether delayed treatment was associated with adverse outcome. Materials and Methods: We included men in the study with lower risk disease managed initially with active surveillance and upgraded to Gleason score 3+4 or greater. Patient demographics and disease characteristics were compared. Kaplan-Meier curve was used to estimate the treatment-free probability stratified by initial upgrade, Cox regression analysis was used to examine factors associated with treatment and multivariate logistic regression analysis was used to evaluate the factors associated with adverse outcome at surgery. Results: The final cohort comprised 219 men, with 150 upgraded to 3+4and 69 to 4+3 or greater. Median time to upgrade was 23 months. A total of 163 men sought treatment, the majority with radical prostatectomy. The treatment-free survival rate at 5 years was 22% for 3+4 and 10% for 4+3 or greater upgrade. Upgrade to 4+3 or greater, higher prostate specific antigen density at diagnosis and shorter time to initial upgrade were associated with treatment. At surgical pathology 34% of cancers were downgraded while 6% were upgraded. Cancer volume at initial upgrade was associated with adverse pathological outcome at surgery. Conclusions: After Gleason score upgrade most patients elected treatment with radical prostatectomy. Among men who deferred definitive intervention, few experienced additional upgrading. At radical prostatectomy only 6% of cases were upgraded further and only tumor volume at initial upgrade was significantly associated with adverse pathological outcome.