Pain in Men Undergoing Transperineal
We assessd the long-term outcomes from a large prospective cohort of men diagnosed with prostate cancer managed with active surveillance and determined the clinical prognostic factors that may predict the risk of metastases.
Materials and Methods:
We retrospectively reviewed data of men enrolled on active surveillance at our institution between 1990 and 2018 with low or intermediate risk disease (stage cT1-2, prostate specific antigen less than 20 ng/ml, and biopsy Grade Group [GG]1-2). Persuasive speech topics were classified into 3 groups by diagnostic GG and prostate specific antigen density. Primary outcome was metastatic prostate cancer detected on imaging or at prostatectomy. In addition, upgrade at surveillance biopsy, active treatment, and overall and prostate cancer specific survival outcomes were assessed. Cox proportional hazards regression models were used.
A total of 1,450 men met the inclusion criteria. Median followup was 77 months (IQR 49–114). The 7-year metastasis-free survival rate was 99%. Metastases developed in 15 men at a median of 62 months (IQR 29–104), of which 69% were confined to lymph nodes. Men with GG2 had a lower metastasis-free survival rate compared to those with GG1 disease. GG2, prostate specific antigen velocity and PI-RADS® 4-5 lesions on multiparametric magnetic resonance imaging were associated with a higher risk of metastases. The 7-year prostate cancer specific survival was greater than 99%.
Active surveillance seems to preserve favorable long-term prognosis, as metastases and prostate cancer specific death are rare. However, the higher risk of metastases associated with higher Gleason grade, prostate specific antigen velocity, and characteristics on multiparametric magnetic resonance imaging should be considered when selecting and counseling patients for active surveillance.
Abbreviations and Acronyms
Active surveillance is generally accepted as the standard of care for those with low risk prostate cancer and in well selected patients with intermediate risk disease. The goal of active surveillance is to avoid or delay the side effects of treatment in men with favorable risk disease without compromising long-term outcomes such as survival or metastasis.
Despite the widespread use of AS, there is still uncertainty regarding optimal candidates and surveillance strategies as well as the long-term risks. There is limited information on longer‐term outcomes, such as metastases and death, because of the low risk of progression and lengthy followup needed to assess hook examples. We aimed to assess the long-term outcomes from a large prospective cohort of men diagnosed with low and intermediate risk PCa initially managed on AS, and determine the clinical prognostic factors that may predict the risk of metastases.
Data were obtained prospectively on men who enrolled on AS at the University of California, San Francisco. Strict AS eligibility criteria included organ confined disease with biopsy Gleason GG1, 33% or less positive biopsy cores and PSA density less than 0.15 ng/ml/cm3, although carefully selected men with other clinical characteristics also were rhetorical analysis essay example. Patients for this analysis were diagnosed between 1990 and 2018 with low or intermediate risk disease, defined as clinical stage T1-2, PSA less than 20 ng/ml, and biopsy GG1 or GG2, and underwent at least 1 biopsy after enrollment. All participants provided written informed consent to participate in research under supervision by the UCSF institutional review board (study 11-05226).
Independent sociodemographic (age, race, relationship status, family history of PCa) and clinical variables at diagnosis (PSA, prostate volume on TRUS, PSAD [defined as PSA divided by prostate volume], clinical stage, biopsy Gleason GG, number of biopsy cores dissected, percentage of positive cores, mpMRI PI-RADS v2, clinical CAPRA score and year) were assessed. Patients were classified into 3 groups for analysis based on the clinical characteristics diagnostic GG1 with PSAD less than 0.15 ng/ml/cm3, diagnostic GG1 with PSAD 0.15 ng/ml/cm3 or greater, and GG2 with any PSAD. Genomic Prostate Score (GPS, or OncotypeDx®) was reported when available. Findings at surgical pathology (pathological GG, stage and margins) were reported for a subset of men who underwent delayed radical prostatectomy. PSA velocity, computed as slope from PSA at diagnosis to last PSA before date of metastases or last followup, was used for multivariate analysis.
The primary outcome event was metastatic PCa detected on imaging (magnetic resonance imaging, computerized tomography, positron emission tomography, or bone scan) or at surgical pathology in those who underwent delayed RP. Secondary clinical outcome events were upgrade on surveillance biopsy GG2 or greater for patients who began with GG1, and GG3 or greater for patients who began with GG2, and receipt of active treatment. Lastly, PCa specific and overall survival outcomes were assessed.
Independent variables were reported with means, medians and frequency tables. Groups were compared with ANOVA for means, Kruskal-Wallis test for medians and Pearson chi-square for categorical variables. Life table product limit estimates were used to informative speech topics. Cox proportional hazards regression models were used to test associations between independent variables and risk of metastases. Cox models were adjusted for characteristics at diagnosis (age, biopsy GG and percentage of positive cores, prostate volume on TRUS and year), high PI-RADS 4-5 on first mpMRI versus no mpMRI, and PSAV. All analyses were performed with SAS® 9.4 for Windows®.