Re: Metastatic Prostate Cancer in Men Initially Treated with Active Surveillance

Active surveillance (AS) in prostate cancer has been advocated as a treatment modality to reduce overtreatment of patients with clinically insignificant disease while appropriately offering radical treatment to those in whom the disease is reclassified as high-risk during surveillance. Yamamoto and coworkers have analyzed their prospective cohort of 993 patients treated with AS and analyzed the characteristics of those who eventually progressed to metastatic disease. Out of 980 evaluable patients, 133 (13.6%) had Gleason score (GS) 7 disease. During AS, 30 patients (3.1%) developed metastases. Of note, metastases developed in 13 of 133 (10%) patients with GS 7 disease. The median time to metastasis was 6.3 years. On univariate analysis, GS 7, number of positive cores, core positivity greater than 50% at initial biopsy, intermediate risk group, and short prostate-specific antigen (PSA) doubling time (DT) were significant risk factors for metastases. On multivariate analysis, GS 7, a total of 3 or more positive cores, and PSA DT remained significant. The presence of Gleason pattern 4 on diagnostic biopsy conferred a threefold to fourfold increased risk of metastatic disease. Even though the authors concluded that GS seven patients should be offered AS with caution, the safety of such a suggestion is quite questionable