Low Risk Prostate Cancer Can And Should Often Be Managed With Active Surveillance And Selective Delayed Intervention

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Men's health
Article Date: 25 Jan 2008 - 0:00 PDT

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UroToday.com- In the November early view of Nature Clinical Practice Urology, Dr. Klotz reviews the strategy for active surveillance (AS) of prostate cancer (CaP). This review will highlight the essential points to implement AS into the practitioners' clinical practice.

Klotz stresses several postulates regarding AS, which are as follows. First, candidates for AS are identified through CaP screening. Favorable-risk CaP is characterized by a Gleason score of <6, PSA <10ng/ml and clinical stage T1c-T2a. Based upon this his initial selection of AS included the following clinical criteria; Gleason score of <6, PSA density <0.15, a total extent of CaP involved of <3mm, an involvement of less than one-third of cores, and an extent of core involvement of <50%. He points out that no treatment is minimal in terms of side effects and costs. Active surveillance is performed in the context of monitoring for patient-risk reclassification. If rapid, PSA progression or Grade progression is found on repeat prostate biopsy then intervention can be performed. The risk for progression to advanced disease in the interim time while on AS is minimal. In his series of 299 men, only 3 progressed to metastatic disease and the PSA kinetics suggested that occult metastasis already existed. As such, a PSA doubling time of less than 3 years or Gleason grade progression to >7 (4+3) would prompt intervention. This must be adjusted based upon the patients' age and health. He points out that the psychological burden of untreated cancer has less impact on the quality of life than the side effects of unnecessary treatment.

In summary, eligibility criteria for AS according to Klotz are:

1. Men <75 years old with a > 10 year life expectancy, PSA <10ng/ml, Gleason score of <6, and clinical stage T1c-T2a

2. For men age 50-60 years old; <3 cores involved with CaP and <50% of any individual core.

The follow-up criteria are:

1. PSA and DRE every 3 months for 2 years, then every 6 months if the PSA is stable.
2. Prostate biopsy with 10-12 cores at 1 year and every 3-5 years until the age of 80 years.

The intervention criteria are:

1. PSA doubling time <3 years or Gleason score progression to >7 (4+3).

These guidelines can be individually adjusted for patient characteristics.

Nat Clin Pract Urol. ePub: November 27, 2007

Reported by UroToday.com Contributing Editor Christopher P. Evans, M.D

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