Progression on active surveillance

Highlights from the Canadian Urological Association Annual Meeting, Montreal, June 2011

Active surveillance (AS) is gaining ground as a viable option for men with low-risk prostate cancer. The following studies presented at the CUA are of interest to men following this approach.

Drugs called 5 alpha-reductase inhibitors (5ARIs), used to treat enlarged prostate (BPH), have already been shown to prevent prostate cancer in two large randomized controlled trials. A study by Finelli et al, presented at the CUA, compared the effect of 5ARIs versus no 5ARIs on cancer progression in 288 low-risk men. All the men had a PSA score <10 ng/mL, stage T1c/T2a, Gleason score ≤6 and ≤3 positive cores with no more than 50% of a core involved and were on AS. After a median follow-up of 38.5 months, 93 men experienced progression (Gleason score >6, maximum core involvement >50%, or >3 cores positive on a subsequent biopsy), and 96 men abandoned AS. The study concluded that the men in the 5ARI group had a lower progression rate and were less likely to stop AS than those in the no-5ARI group, thus confirming the benefits of these medications for men with low-risk prostate cancer. (There is still some controversy around 5ARIs, as some studies have also shown that they are associated with higher-grade cancers.)

A second study by Fradet et al evaluated the usefulness of the urinary PCA3 test as a predictor of cancer progression in men on AS. Enrolled patients had Gleason score 6 and received a prescription for a 5ARI. They had repeat prostate biopsies after six to 12 months of AS, then yearly, with urine samples taken before the biopsies. The results showed that the PCA3 test predicts cancer progression (or higher grade cancer that was missed at diagnosis) for men under AS, and suggest that this test may help in selecting which men will most benefit from this management approach.