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Low risk

  • Extended followup and risk factors for disease reclassification in a large active surveillance cohort for localized prostate cancer

    J Urol. 2015 Mar;193(3):807-11

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    Comment from Henk van der Poel:  The field of active surveillance management of low risk prostate cancer is completely void of randomized studies. Rather surprising considering the tremendous impact of a delayed diagnosis of high risk prostate cancer for several years. At 5 years prostate cancer specific mortality is low despite biopsy reclassification in the majority of men. Longer follow-up is needed to answer the question whether AS is delaying rather than preventing treatment and whether this delay will result in PCA related death in some.
  • Fluoroquinolone resistance in the rectal carriage of men in an active surveillance cohort: longitudinal analysis

    J Urol. 2015 Feb;193(2):552-6.

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    Comment from Henk van der Poel: Although resistance to quinolone in rectal swab was frequent (>20%) it was not associated with earlier prostate biopsies. Targeted AB prophylaxis for biopsies, certainly in men with diabetes, should be considered.
  • Active surveillance for localized prostate cancer: an analysis of patient contacts and utilization of healthcare resources

    Scand J Urol. 2015 Feb;49(1):43-50

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    Comment from Henk van der Poel: Randomized studies on active surveillance are lacking. Progression to treatment after AS is high in the first 5 years, however AS provided a 35% cost reduction in the first years as compared to immediate treatment.
  • Comparison of MR/ultrasound fusion-guided biopsy with ultrasound-guided biopsy for the diagnosis of prostate cancer

    JAMA. 2015 Jan 27;313(4):390-7

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    Comment from Henk van der Poel: Targeting the way to go: 30% more high risk cancers detected and 17% less low risk. Time to set sextant biopsies aside.
  • Systematic Review and Meta-analysis of Factors Determining Change to Radical Treatment in Active Surveillance for Localized Prostate Cancer

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    Comment from Henk van der Poel: Most crucial question: are patients that opt for active surveillance at increased risk of progression after local treatment for their prostate cancer? The different criteria used for prediction of inclusion and progression in 26 studies resulted in an active treatment rate of 1-22% per person year. Indications for change to active treatment were ranged, but at forest plot analysis rebiopsy gleason grade was the most frequently reported indication for active treatment in almost 40%. Follow up was short (<5y) which suggests that the observed upgrading is more due to undersampling than biological progression.
  • Anxiety in the management of localised prostate cancer by active surveillance

    BJU Int. 2014 Nov;114 Suppl 1:55-61.

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    Comment from Henk van der Poel: Anxiety levels in men on active surveillance for low risk prostate cancer were low. In this study response rate was disturbingly low (33%), but of the men that did show a QOL rsponse, it was high. It remains unclear whether the majority of men did not response because of disinterest or anxiety. It would be interesting to assess anxiety in those men that will experience progression and secondary need for local treatment.
  • Physician variation in management of low-risk prostate cancer: a population-based cohort study

    Hoffman KE, Niu J, Shen Y, Jiang J, Davis JW, Kim J, Kuban DA, Perkins GH, Shah JB, Smith GL, Volk RJ, Buchholz TA, Giordano SH, Smith BD.

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    Comment from Henk van der Poel: Do we give impartial advice? Or who is unbiased? Early analyses showed a preferential treatment advice dependent on the main treatment modality provided by a specific physician. Urologist were more likely to provide prostatectomy, whereas radiation oncologist preferentially used radiotherapy and men consulting a medical oncologist were more likely to receive an initial active surveillance management of low and intermediate risk prostate cancer.  In a large cohort of patients (12.000) with low risk prostate cancer diagnosed over the age of 65 year treatment was analyzed. The majority of men (80%) with low risk disease received treatment. Men seen by urologists only, a urologist with more years after training and urologists that treat non-low-risk prostate cancer were all significantly more likely to undergo treatment as opposed to an (active) surveillance approach. In men visiting the radiation oncologist upfront treatment was even higher than for urologists: over 90%. Between 2006 and 2009 an  increasing rate of observation was noted (from 17.5% to 25.1%) indicating that the field is continuously shifting and data from 8 years ago may and should not affect nowadays decision-making on the topic of active surveillance. With an increase in life-expectancy data from the SPCG-4 trial, in some cases even before the PSA era should be interpreted with caution. Although active surveillance adaptation will continue to improve, with longer follow up the “progression” rate leading to active treatment in men initially managed conservatively is shown to exceed 50%. Finally, although urologists seem to advice active treatment in many men with low risk prostate cancer, they don’t stand alone. Also radiation oncologists tend to shy away form active surveillance and perform active treatment in over 90% over referred men with low risk prostate cancer.
  • Plasma vitamin D and prostate cancer risk: results from the Selenium and Vitamin E Cancer Prevention Trial

    Kristal AR, Till C, Song X, Tangen CM, Goodman PJ, Neuhauser ML, Schenk JM, Thompson IM, Meyskens FL Jr, Goodman GE, Minasian LM, Parnes HL, Klein EA.

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    Comment from Henk van der Poel: Both low and high Vit D plasma levels found to increase prostate cancer risk in the SELECT trial population. Vit D supplementation may increase PCA risk.

    In the PCPT trial elevated serum vit D levels were also associated with increased incidence of Gleason 2-6 but with a reduced risk of Gleason 8-10 cancers in both the placebo and finasteride study arm.

    It is suggested that this apparent contradiction is caused by selection bias in the SELECT trial population (Schwartz cancer epidemiol biom prev 23:1447, 2014) and that indeed vit D may decrease the incidence of higher risk prostate cancer as suggested by the PCPT findings.

  • Novel Tools to Improve Patient Selection and Monitoring on Active Surveillance for Low-risk Prostate Cancer: A Systematic Review

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    Comment from Henk van der Poel:
    MRI imaging may be a powerful tool to select men for active surveillance in prostate cancer as suggested by a systematic review of the literature. The high negative predictive value of MRI may obviate the need of repeat biopsies in an active surveillance program
  • Radical prostatectomy or watchful waiting in early prostate cancer.

    Bill-Axelson A. Holmberg L. Garmo H. Rider J.R. Taari K. Busch C. Nordling S. Haggman M. Andersson S.-O. Spangberg A. Andren O. Palmgren J. Steineck G. Adami H.-O. Johansson J.-E.

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    Comment by Henk van der Poel:
    In clinical prostate cancer prostatectomy was shown to improve survival also at longer follow up with an absolute risk reduction in death from prostate cancer of 11% and a number needed to treat to prevent one prostate cancer death of 8. Younger men and men with intermediate risk prostate cancer were most likely to benefit. Interestingly, prostatectomy did reduce the risk of metastases in older men. For men treated with watchful-waiting the risk of dying at 18 years was 68.9% versus 56.1% for the prostatectomy treated men. This all comes with a price: earlier data show an almost 4x higher risk of urinary leakage in the prostatectomy group, with surprisingly, comparable erectile dysfunction rates for both arms. Is 18 years long enough. Certainly for men under 65 years of age longer follow up is warranted, in particular considering the risk of metastases in the prostatectomy arm of 26.1% at 18 years.

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