Introduction: Active surveillance for prostate cancer is a therapeutic option which is gaining more popularity. Implicit in this approach is careful monitoring to identify those with progression. Criteria for placing patients on active surveillance vary but generally include Gleason sum of 6 or less, prostate-specific antigen (PSA) less than 20, and a small volume of cancer in the biopsy specimen. We review our experience with active surveillance in a veteran population.
Materials and methods: We conducted a retrospective review of patients from the Kansas City Veterans Affairs (KCVA) who met the requirements for active surveillance (Gleason sum 6, percent of cancer in the specimen less than 20%, and PSA less than 20 ng/dL) between January 2004 and December 2009. In the patient group who chose active surveillance (AS), we evaluated the rates of compliance with the protocol mandated PSA's and the 1 year biopsy. In the patient group who declined AS and underwent immediate prostatectomy, we reviewed the final pathology for stage, Gleason grade, percent of tissue involved with cancer, margin status, nodal status, and rates of biochemical recurrence.
Results: We identified 207 patients who met the requirements for active surveillance. Of these patients, 45 patients chose active surveillance while 66 patients underwent immediate radical prostatectomy at the KCVA. Of the 45 patients who went on active surveillance, all participants had at least one PSA drawn. However, only 24 (53.3%) patients complied with the protocol mandated prostate biopsy at 1 year. In the patient group who chose to undergo an immediate prostatectomy, 43 of 66 (65.2%) patients had upgrading of their Gleason score. This included 12 patients upgraded to Gleason sum 8 to 10 and two patients who were upstaged to T3 disease. Despite the significant upgrading, only two patients have had a biochemical recurrence at a median follow up of 30 months.
Conclusions: Active surveillance is a viable option for patients with low risk prostate cancer. However, this study raises concerns about compliance with recommendations for active surveillance in a VA population. Furthermore, there was a significant risk in this study of under-grading in patients who underwent immediate prostatectomy. This emphasizes the need for better education of patients who enter into active surveillance protocols regarding the need for compliance, the risks of progression, and the chance of under grading.