UroToday - Low-risk Prostate Cancer Can and Should Often be Managed with Active Surveillance and Selective Delayed Intervention

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Friday, 25 January 2008

BERKELEY, CA

(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:

Men <75 years old with a > 10 year life

expectancy, PSA <10ng/ml, Gleason score of <6, and clinical stage

T1c-T2a

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.

Prostate biopsy with 10-12 cores at 1 year and

every 3-5 years until the age of 80 years.

The

intervention criteria are:

PSA doubling time <3 years or Gleason score

progression to >7 (4+3).

These

guidelines can be individually adjusted for patient characteristics.

ce

Klotz

Nat

Clin Pract Urol. ePub: November 27, 2007

doi:10.1038/ncpuro0993

PubMed

Abstract

PMID:18043601