113
Active Surveillance of Prostate
Cancer
Herbert Ballentine Carter; Marc Arnaldo Dall-Era
Questions
1.Watchful waiting is appropriate for men who:
a.are 70 years of age or older.
b.have impalpable cancer not visible on imaging studies.
c.have a serum prostate-specific antigen (PSA) level less than 10 ng/mL.
d.have a life expectancy approximately 10 years or less and well to moderately differentiated cancer.
e.have no major comorbidities.
2.Which of the following is important for monitoring men on watchful waiting?
a.Periodic PSA testing
b.Serial transrectal ultrasound
c.Repeat prostate biopsy
d.Endorectal magnetic resonance imaging (MRI)
e.None of the above
3.For men with well or moderately differentiated prostate cancer on watchful waiting, the 10-year cancer-specific mortality is approximately:
a.1%.
b.5%.
c.15%
d.30%.
e.50%.
4.For men with well-differentiated prostate cancer, the rate of metastases within the first 10 years of watchful waiting is approximately:
a.5%.
b.10%.
c.20%.
d.50%.
e.75%.
5.Compared with men treated by radical prostatectomy, men on watchful waiting have a higher risk of:
a.bowel problems.
b.obstructive voiding problems.
c.metastases.
d.death from prostate cancer.
e.all of the above.
6.The best way to select men for active surveillance is:
a.age at the time of cancer diagnosis.
b.life expectancy.
c.PSA level.
d.results of imaging studies.
e.assessment by multiple variables such as Epstein's risk assessment or nomogram.
7.During follow-up of men on active surveillance, how is digital rectal examination (DRE) most valuable?
a.DRE is an indicator that a repeat biopsy is warranted.
b.DRE is a means to assess prostate size as an indication for transurethral resection of the prostate.
c.DRE is an indicator to order an imaging study such as transrectal ultrasound or endorectal MRI.
d.DRE is a predictor of cancer progression.
e.DRE has no apparent value in this setting.
Answers
1.d. Have a life expectancy approximately 10 years or less and well to moderately differentiated cancer. Watchful waiting is a reasonable option in patients with a life expectancy of 10 years and clinically localized, welldifferentiated, or moderately differentiated prostate cancer.
2.e. None of the above. Because the goal of watchful waiting is to limit morbidity and not to administer potentially curative treatment, PSA testing, repeat biopsy, and imaging studies are unimportant.
3.c. 15%. According to a study by Bill-Axelson and colleagues (2008),* men
who were managed conservatively had a 14% cancer-specific mortality rate at 10 years after diagnosis.
4.c. 20%. Chodak and colleagues (1994) found that, for men with welldifferentiated, clinical stage T1 to T2 cancer managed conservatively, the risk of metastasis at 10 years was 19%.
5.e. All of the above. In a randomized comparison of watchful waiting and radical prostatectomy in Sweden, men on watchful waiting experienced significantly more obstructive voiding complaints, bowel problems, metastases, and death from prostate cancer.
6.e. Assessment by multiple variables such as Epstein's risk assessment or nomogram. Models that incorporate multiple factors have proven to be better predictors of indolent prostate cancer than any single factor.
7.a. DRE is an indicator that a repeat biopsy is warranted. None of the current active surveillance studies has found DRE to be an independent predictor of cancer progression, although it can be useful in determining that a repeat biopsy should be taken.
Chapter review
1.Forty-two percent of American men 50 years or older who die of causes other than prostate cancer have prostate cancer at autopsy.
2.In the prostate cancer prevention trial it was found that 6.2% of men with a PSA less than 0.5 ng/mL and 25% of those with a PSA between 2.1 and 4 ng/mL had prostate cancer on biopsy.
3.It is generally accepted that organ-confined cancer less than 0.5 mL in volume with no Gleason grade 4 or 5 component is indolent and poses little if any risk to the patient.
4.Current estimates suggest that 20% to 40% of prostate cancers that are detected would never have been found in a subject's lifetime without screening—in other words, will never affect the patient's life.
5.The criteria generally used for selection of individuals for active observation include (a) no Gleason grade 4 or 5 in the biopsy; (b) no more than three cores positive, none of which is more than 50% involved (some suggest that there should be less than 3 mm of total involvement in the biopsy cores); (c) no palpable disease (controversial); and (d) a PSA less than 10 ng/mL with a PSA density less than
0.15ng/mL per gram of tissue.
6.In most series of patients on active observation, approximately a third
during a period of 5 years will receive definitive treatment.
7.PSA kinetics are extremely complex, so it is difficult to establish specific PSA criteria that predict progression.
8.A repeat biopsy is an integral part of all active observation protocols.
9.Indications for abandonment of active observation are an increased amount of cancer on repeat biopsy, an increased Gleason sum, a rapidly rising PSA, and patient anxiety.
10.Definitive therapy for disease progression in those on active observation appears to be effective in the majority of patients, although no long-term studies are available to firmly establish this.
11.Ten-year cancer-specific mortality for low-risk prostate cancer is approximately 3%.
12.Men with intermediate-and high-risk prostate cancer appear to benefit from treatment.
13.Approximately one third of patients will be upgraded on active surveillance during a 10-year period.
14.Endorectal MRI with diffusion weighting and contrast enhancement has a high negative predictive value and may be of help in selecting patients for active observation, although there are no prospective studies that would confirm this.
15.More extensive biopsies during the standard 12-core biopsy have not been shown to be helpful in patient selection for active observation.
* Sources referenced can be found in Campbell-Walsh Urology, 10th Edition, on the Expert Consult website.