Active surveillance in intermediate risk prostate cancer: is it safe?

Most men with prostate cancer will not die from it. Although the most frequent cancer in men in the western world it ranks only 3rd place for cause of death (1). In men over 60 years of age prostate cancer is found at autopsy in over 60% (2). Overdiagnosis by PSA screening is estimated to be 57% when screened until 75 years of age (3). Considering treatment toxicity, careful selection of men for treatment is essential. A shift towards more conservative management is apparent in larger registries (4, 5). In large cohorts of men with biopsy Gleason 6 cancer adverse pathology at prostatectomy is observed in over one-third of men (6, 7) suggesting undersampling of Gleason 7 cancer that is often present in men with Gleason 6 prostate cancer on biopsy. Even in men with very low risk at biopsy (T1c, PSAD<0.15, GS<7, <3 positive cores containing less than 50% cancer), one in 10 will have significant disease at prostatectomy (8). Reese et al. (9) found the presence of Gleason 7 at biopsy a strong predictor of adverse pathology at prostatectomy. Based on a large prostatectomy series Ploussard et al. (10) concluded that although 46% of men with biopsy Gleason 7 prostate cancer had poor prognostic characteristics at prostatectomy such as upgrading or upstaging at final pathology a subgroup of men with PSA<10ng/ml, PSAD <0.15 cT1c and less than 3 positive cores this risk was only 19% suggesting that in selected men with intermediate risk cancer with otherwise favorable characteristics conservative management can be considered. Gleason score 7 on biopsy, therefore, does not exert a poorer outcome perse and smaller lesions with this Gleason score may have similar outcome when compared to Gleason 6 prostate cancer on biopsy. The amount of high grade (5) cancer in both biopsy and prostatectomy was found predictive of outcome, rather than Gleason score (11). These observations show that Gleason 7 on biopsy not necessarily indicates poorer prognosis than Gleason 6 in men with limited Gleason grade 4 disease. Large randomized studies were unable to show a survival benefit of local treatment versus observation in men with Gleason 6 prostate cancer in whom active surveillance is frequently (12). DIffERENCE Of OpINION