Platinum Priority – Prostate CancerEditorial by XXX on pp. x–y of this issueActive Surveillance of Grade Group 1 Prostate Cancer: Long-term Outcomes from a Large Prospective Cohort
Introduction
Active surveillance (AS) is the preferred management strategy for most men with grade group (GG) 1 prostate cancer (PCa) [1]. One concern surrounding AS has been the loss of a window of curability during the course of monitoring [2]. Over the past 2 decades, however, longitudinal data from several institutions have demonstrated the overall safety of AS, with 5- and 10-yr cancer-specific survival rates consistently exceeding 94% [3], [4], [5], [6], [7]. These findings have led to widespread acceptance of AS and its endorsement in clinical guidelines [8].
Nonetheless, many important questions persist regarding AS. First, data are limited regarding the durability of AS beyond 10 yr [2], [3]. Second, the impact of patient-level demographic factors on outcomes remains unclear [1]. Moreover, serial prostate biopsies central to surveillance protocols [3], [4] are associated with significant risks [9], and the role of multiparametric magnetic resonance imaging (mpMRI) as an alternative to biopsy is unclear [2]. We herein report outcomes from a large, prospective AS program with long-term follow-up, including our initial experience using mpMRI.
Section snippets
Prospectively defined AS program
The Johns Hopkins AS program was initiated in 1995 as an option for men with very-low-risk (VLR) PCa [10], defined as clinical stage T1c, prostate-specific antigen (PSA) density (PSAD) <0.15 ng/ml, GG1, two or fewer positive biopsy cores, and ≤50% cancer involvement of any biopsy core [11]. Over time, an increasing number of patients were enrolled with low-risk (LR; clinical stage ≤T2a, PSA <10 ng/ml, and GG1) cancer (Supplementary Fig. 1).
All men were recommended to undergo follow-up biopsy
Study cohort
From January 1995 through June 2018, 1818 men with VLR and LR PCa were enrolled in AS (Table 1). The median follow-up for men at risk of upgrading was 5.0 yr (interquartile range [IQR] 2.0–9.0), and the median interval between biopsies was 13 mo (IQR 12–15). In total, 920 men had ≥5 yr of follow-up and 305 had ≥10 yr of follow-up. The cumulative incidences of ongoing cancer assessment (defined as: PSA, mpMRI, and/or prostate biopsy within 18 mo) at 3, 5, and 10 yr after diagnosis were 94%, 88%, and
Discussion
AS is a widely accepted management option for men with GG1 PCa [1], [2], [8], but questions persist regarding long-term outcomes and the optimal approach to patient selection and monitoring [2], [3], [4]. Consistent with previous findings [4], the current analysis revealed 10- and 15-yr cumulative incidences of PCSM or metastasis to be <1%. Accordingly, we observed a 22-fold increased risk of dying from non-PCa causes than from PCa at the end of the overall study period. On multivariable
Conclusions
These data support the safety of AS as a guideline-endorsed, first-line management approach in most men with GG1 PCa. Patients should be counseled with regard to their personal preferences and informed of the limitations of currently available data. With additional follow-up of our cohort and others, optimal use of mpMRI and other technologies will be better defined, and the approach to AS will continue to evolve toward a sufficiently thorough, less invasive ideal.
Author contributions: Mufaddal
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These authors contributed equally to this report.