Natanlie Perez

© 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.