PCa18: Case discussions on active surveillance- an evolving topic

14 September 2018

The afternoon breakout Case Discussions which provided PCa18 participants the opportunity to closely look into the details of prostate cancer (PCa) management dilemmas covered the still-evolving issue of active surveillance, its importance and significance particularly with regards elderly patients with aggressive prostate disease.

Professors M. Roobol (NL) and O. Bratt (SE) examined in their lectures the issue “Active surveillance: Patient selection and follow-up,” with both speakers underscoring the evolution of active surveillance (AS) within the context of changes in grading definitions and the entry of new technology such as Magnetic Resonance Imaging (MRI).

“AS is about the monitoring of a cancer tumour that we expect to grow very slowly, to be able to detect and treat it, if it grows faster than we expected,” said Bratt in his introductory remarks.

“But the changed grading definitions (ISUP 2005) and the improved understanding of the biology of low-grade grade prostate cancer changed our view of AS,” explained Bratt adding that Gleason score 6 cancers “are almost always indolent“, and as such AS is about excluding undetected high-grade cancer in order “to detect new lesions and to monitor defined lesions.”

According to Bratt, with the growing use of MRI the issue of AS has also changed. He conducted a PubMed search that covered the last three years to search for the terms “active surveillance AND prostate cancer AND magnetic/MRI” which yielded around 189 articles. With a search restricted to “Clinical Trial” Bratt said it only led to one article- the ASIST study.

He said most published studies are retrospective, single-institution reports and with unknown selection bias.

“The evidence base is poor! The message here is that we need to include patients in prospective trials,” Bratt said.

Meanwhile, Roobol discussed eligibility and follow-up criteria and gave an overview on what current guidelines recommend regarding AS.

In her concluding remarks, Roobol said: “AS is currently recommended according to strict protocols.” Highlighting the impact of these restrictive protocols, she said:

“Compliance to those protocols is moderate to poor (PRIAS data) and screening causes lead time, approximately 10 years,” she said. “In the first years of AS (after confirmation of stage and grade), a relaxed protocol to assure long-term compliance is recommended.”

Additionally, Roobol said, whether AS will be obsolete in the future is a question that is still uncertain, adding the likely scenario will be that AS is suitable for men with higher grade PCa.