Active surveillance for prostate cancer: a narrative review of clinical guidelines

In the past decade active surveillance (AS) of men with localized prostate cancer has become an increasingly popular management option, and a range of clinical guidelines have been published on this topic. Existing guidelines regarding AS for prostate cancer vary widely, but predominantly state that the most suitable patients for AS are those with pretreatment clinical stage T1c or T2 tumours, serum PSA levels <10 ng/ml, biopsy Gleason scores of 6 or less, a maximum of one or two tumour-positive biopsy core samples and/or a maximum of 50% of cancer per core sample. Following initiation of an AS programme, most guidelines recommend serial serum PSA measurements, digital rectal examinations and surveillance biopsies to check for and identify pathological indications of tumour progression. Definitions of disease reclassification and progression differ among guidelines and multiple criteria for initiation of definitive treatment are proposed. The variety of descriptions of criteria for clinically insignificant prostate cancer indicates a lack of consensus on optimal AS and intervention thresholds. A single set of guidelines are needed in order to reduce variations in clinical practice and to optimize clinical decision-making. To enable truly evidence-based guidelines, further research that combines existing evidence, while also gathering information from more long-term studies is needed.This study is linked to a larger project, the Movember Foundation's Global Action Plan on active surveillance for low-risk prostate cancer (GAP3), which is collaboration between institutions, hospitals and research centres in Australia, Canada, France, Finland, Italy, Japan, Netherlands, UK and the USA. The Movember Foundation has invested €1,664,950 in the GAP3 project in order to create the largest centralized database on AS in men with prostate cancer to date, comprising around 40% of all global patient data on AS. The funder did not play any role in the study design, collection, analysis or interpretation of data, or in the drafting of this paper

MRI in active surveillance: a critical review

INTRODUCTION: Recent technological advancements and the introduction of modern anatomical and functional sequences have led to a growing role for multiparametric magnetic resonance imaging (mpMRI) in the detection, risk assessment and monitoring of early prostate cancer. This includes men who have been diagnosed with lower-risk prostate cancer and are looking at the option of active surveillance (AS). The purpose of this paper is to review the recent evidence supporting the use of mpMRI at different time points in AS, as well as to discuss some of its potential pitfalls. METHODS: A combination of electronic and manual searching methods were used to identify recent, important papers investigating the role of mpMRI in AS. RESULTS: The high negative predictive value of mpMRI can be exploited for the selection of AS candidates. In addition, mpMRI can be efficiently used to detect higher risk disease in patients already on surveillance. CONCLUSION: Although there is an ongoing debate regarding the precise nature of its optimal implementation, mpMRI is a promising risk stratification tool and should be considered for men on AS

Positive predictive value of prostate biopsy indicated by prostate-specific-antigen-based prostate cancer screening: trends over time in a European randomized trial

OBJECTIVE To assess the positive predictive value (PPV) of prostate biopsy, indicated by a prostate-specific antigen (PSA) threshold of =3.0 ng/mL, over time, in the Rotterdam section of the European Randomized study of Screening for Prostate Cancer (ERSPC). PATIENTS AND METHODS In the Rotterdam section of the ERSPC, a total of 42 376 participants, aged 5574 years, identified from population registries were randomly assigned to a screening or control arm. For the ERSPC men undergo PSA screening at 4-year intervals. A total of three screening rounds were evaluated; therefore, only men aged 5569 years at the first screening were eligible for the present study. RESULTS PPVs for men without previous biopsy remained equal throughout the three subsequent screenings (25.5, 22.3 and 24.8% respectively). Conversely, PPVs for men with a previous negative biopsy dropped significantly (12.0 and 15.2% at the second and third screening, respectively). Additionally, in men with and without previous biopsy, the percentage of aggressive prostate cancers (clinical stage >T2b, Gleason score =7) decreased after the first round of screening from 44.4 to 23.8% in the second (P < 0.001) and 18.6% in the third round (P < 0.001). Repeat biopsies accounted for 24.6% of all biopsies, but yielded only 8.6% of all aggressive cancers. CONCLUSIONS In consecutive screening rounds the PPV of PSA-based screening remains equal in previously unbiopsied men. In men with a previous negative biopsy the PPV drops considerably, but 20% of cancers detected still show aggressive characteristics. Individualized screening algorithms should incorporate previous biopsy status in the decision to perform a repeat biopsy with the aim of further reducing unnecessary biopsies