Introduction and Objectives – Low risk prostate cancer (LRPC) overdiagnosis has become more frequent, raising concerns on the morbidity induced by subsequent overtreatment. Active surveillance (AS) is an alternative in these indolent tumors, allowing the postponement or avoidance of radical treatments, without compromising cancer-specific survival (CSS). We aimed to compare outcomes of AS and radical prostatectomy (RP) in the approach of patients with LRPC.
Material and Methods – Retrospective clinical data was gathered on men with very low-risk PC (biopsy Gleason score <7; ≤ 3 positive biopsy cores with ≤ 25% tumor involvement in each positive core; PSA < 10ng/dL; stage ≤ cT2a) between January 2012 and July 2017, and either included in the AS protocol or submitted to RP. Triggers for AS discontinuation were disease progression in re-biopsies; suspected PSA kinetics; patient’s will. Analyzed outcomes were CSS, metastasis-free survival (MFS) and postoperative functional outcomes.
Results – Sixty six (66) patients were included: 31 initially submitted to RP (group 1) and 35 included in the AS protocol (group 2). Mean age was 65.6 ± 5.2 years old in group 1 and 68.2 ± 5.4 in group 2. Mean initial PSA was 7.8 ± 2.7 ng/dL and 6.3 ± 3.9 ng/dL in groups 1 and 2. After 44.5 ± 26.9 months of follow-up, AS discontinuation rate was 30.6% (11 cases, 4 for Gleason progression after 39.7 ± 11.1 months of AS). Seven of these patients were submitted to RP (two reported cases of reupstaging), and 2 received radiotherapy. Regarding group 1, final pathology revealed an upgrade to ISUP group ≥ 2 in 13 cases (41.9%) comparing to biopsy. One patient died during surgery due to an acute myocardial infarction. As for functional outcomes, 5 patients (16.1%) report some degree of stress urinary incontinence and 20 (64.5%) have erectile disfunction. No cases of cancer-related mortality or metastatic disease were reported in both groups.
Conclusions– We report good results in our department's protocol, with a 30.6% discontinuation rate but only 4 cases triggered by disease progression. Functional morbidity in patients initially submitted to RP was not neglectable and could have been delayed or avoided by AS. However, an alarming 41.9% of cancers initially submitted to surgery were upstaged in RP specimen, also raising the need for an accurate initial staging before selecting patients for AS. The introduction of multiparametric MR will probably minimize some of these problems.
