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Active surveillance

Active surveillance is a strategy which aims to avoid unnecessary treatment of localised prostate cancer, whilst maintaining a curative window for those who develop a need for treatment.

  • Patients remain under structured surveillance with follow up including PSA testing, examination, imaging and biopsies
  • It aims to minimise or avoid treatment related toxicities, without compromising prostate cancer specific survival

Rationale for active surveillance:

  • Lead time from diagnosis to clinical progression is usually long
  • Treatment of prostate cancer does carry morbidity
  • Initial assessment and subsequent monitoring can be quite accurate at assessing risk

It differs from watchful waiting – where patients who are unsuitable for curative intent treatment are conservatively managed and ‘watched’ for progression. These men are treated with palliative intent – aimed at treating symptoms (or impending symptoms) to maintain quality of life.

Graphical user interface, table Description automatically generated

Above table from EAU guidelines

Evidence for active surveillance

There are several cohorts who have been followed prospectively now for many years, but there is significant heterogeneity in inclusion criteria and follow up.

Meta-analysis of available studies (Thomsen 2014):

  • > 96 (mostly 99) % cancer specific survival at 10 years
  • Approx 33 % discontinuation of AS at 5 years, and 55 % at 10 years

No formal RCT comparing AS to active treatment.

ProtecT compared active monitoring to treatment, which is a less stringent surveillance strategy.

  • No difference in cancer specific or overall survival at 10 years, with 25 % of the surveillance group treated within 3 years and about 55 % treated by 10 years
  • There was a higher rate of clinical progression or distant metastasis in monitoring group

Inclusion criteria / who should be offered surveillance

PCFA:

  • Offer surveillance to men with
    • PSA < 20 ng / mL
    • cT1-2
    • ISUP 1 disease
  • Considering offering surveillance to men with
    • ISUP 2, with Gleason 4 component < 10 %, and PSA < 10

“Advise men with low risk prostate cancer that, if they choose AS, their risk of death due to prostate cancer over the next 10 years would be low, and probably no greater than if they were to choose immediate definitive treatment”

DETECTIVE consensus:

  • Offer AS to patients with > 10 year life expectancy, and low-risk disease
  • Exclude if extent or stage of disease is high on mpMRI
  • ISUP 2 can be included if PSA < 10, cT2a or lower, and favourable biopsy characteristics / low core positivity
  • Exclude ISUP 3, cT2c

Surveillance protocol

There are multiple different protocols in different trials and no universally accepted criteria.

PCFA recommendation:

  • PSA measurements every 3 months, DRE every 6 months
  • Reclassification biopsy at 6 – 12 months, then every 2 – 3 years, or as needed, based on PSA/MRI/DRE
  • Consider using MRI

DETECTIVE consensus:

  • If a patient has had upfront MRI followed by systematic and targeted biopsies, there is no need for confirmatory biopsies
  • PSA every 6 months
  • DRE every 12 months
  • Repeat biopsy if MRI changes, DRE progression
  • Unclear if repeat biopsy should be performed in the absence of any triggers

Reclassification / treatment trigger:

DETECTIVE consensus:

  • Patient anxiety / desire for treatment is a valid reason to reclassify and treat
  • Decision for treatment should generally be guided by biopsies, not PSA, DRE or MRI changes

Active surveillance in my hands

  • Offered to all patients with low risk disease – ISUP 1, PSA < 10
  • Offered to men with ISUP 2 disease if low volume Gleason pattern 4 on biopsies, accepting slightly higher risk than ISUP 1
  • Mentioned as an option for other ISUP 2 disease, but not recommended, and not supported by evidence
  • Initial MRI followed by systematic and targeted transperineal biopsy
  • PSA 6 monthly, and annual DRE
  • Low threshold for repeat biopsy at 6 – 12 months, particularly if concerns re: PSA, ISUP 2, PSA density, MRI lesion, or high volume ISUP 1
  • Decision to treat generally based on upgrading to any Gleason pattern 4, or increase in volume

How to calculate life expectancy?

Issues:

  • Screening PSA detected cancers are found in generally healthier men – ‘healthy screener bias’
  • Physicians and urologists shown to be about 80 % accurate with estimations, trending towards underestimating life expectancy
  • Actuarial calculators available – usually use gender, age, weight, height, smoking, alcohol, driving, blood pressure
  • ABS data:
    • 65 year old can expect to live to 85
    • 75 year old can expect to live 87
    • 78 year old has 10 year life expectancy to 88
    • 85 year old can expect to live to 91