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PATHOLOGY
doi: 10.1590/S1677-55382011000200021
Active
surveillance program for prostate cancer: an update of the Johns Hopkins
experience
Tosoian JJ, Trock BJ, Landis P, Feng Z, Epstein JI, Partin AW, Walsh PC,
Carter HB
The Johns Hopkins University School of Medicine, The James Buchanan Brady
Urological Institute, and Johns Hopkins Hospital, Baltimore, MD
J Clin Oncol. 2011; 4. [Epub ahead of print]
- Purpose:
We assessed outcomes of men with prostate cancer enrolled in active
surveillance.
Patients and Methods: Since 1995, a total of 769 men diagnosed with
prostate cancer have been followed prospectively (median follow-up,
2.7 years; range, 0.01 to 15.0 years) on active surveillance. Enrollment
criteria were for very-low-risk cancers, defined by clinical stage (T1c),
prostate-specific antigen density < 0.15 ng/mL, and prostate biopsy
findings (Gleason score = 6, two or fewer cores with cancer, and = 50%
cancer involvement of any core). Curative intervention was recommended
on disease reclassification on the basis of biopsy criteria. The primary
outcome was survival free of intervention, and secondary outcomes were
rates of disease reclassification and exit from the program. Outcomes
were compared between men who did and did not meet very-low-risk criteria.
Results The median survival free of intervention was 6.5 years (range,
0.0 to 15.0 years) after diagnosis, and the proportions of men remaining
free of intervention after 2, 5, and 10 years of follow-up were 81%,
59%, and 41%, respectively. Overall, 255 men (33.2%) underwent intervention
at a median of 2.2 years (range, 0.6 to 10.2 years) after diagnosis;
188 men (73.7%) underwent intervention on the basis of disease reclassification
on biopsy. The proportions of men who underwent curative intervention
(P = 0.026) or had biopsy reclassification (P < 0.001) were significantly
lower in men who met enrollment criteria than in those who did not.
There were no prostate cancer deaths.
Conclusion: For carefully selected men, active surveillance with curative
intent appears to be a safe alternative to immediate intervention. Limiting
surveillance to very-low-risk patients may reduce the frequency of adverse
outcomes.
- Editorial
Comment
The authors studied the outcomes of men with prostate cancer enrolled
in active surveillance comparing patients who did and did not meet very-low-risk
criteria. Very-low-risk was defined according to the contemporary analysis
of Bastian et al. for Epstein’s criteria for insignificant cancer
on needle biopsy: clinical stage T1c, prostate-specific antigen density
< 0.15 ng/mL, Gleason score = 6, two or fewer cores with cancer,
and = 50% cancer involvement of any core.
During the follow-up period the proportions of men who underwent curative
intervention (p = 0.026) or had biopsy reclassification (more than 2
cores, Gleason score > 6, or > 50% cancer involvement of any core)
(p < 0.001) were significantly lower in men who met very-low-risk
criteria. There were also no prostate cancer deaths in this cohort of
patients.
The authors conclude that for carefully selected men, active surveillance
limited to patients with very-low-risk cancers according to Epstein’s
criteria for insignificant cancer may significantly reduce the frequency
of adverse outcomes.
Reference
- Bastian
PJ, Mangold LA, Epstein JI, Partin AW: Characteristics of insignificant
clinical T1c prostate tumors. A contemporary analysis. Cancer. 2004;
101: 2001-5.
Dr.
Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
E-mail: athanase@fcm.unicamp.br
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