Chapter 32: Genitourinary Disorders

ACTIVE SURVEILLANCE (AS) FOR THE MANAGEMENT OF LOCALIZED PROSTATE CANCER

Population

• –Men with early clinically localized prostate cancer (Stages T₁ and T₂ and Gleason score less than or equal to 7).

Recommendations

CCO 2016, ASCO 2016

• –For most patients with low-risk (Gleason score 6 or less) localized prostate cancer with a PSA <10, active surveillance (AS) is the recommended disease management strategy.

• –Younger age, high-volume Gleason 6 cancer, patient preference, and/or African American ethnicity should be taken into account since definitive therapy may be warranted for select patients.

• –For patients with limited life expectancy (<5 y) and low-risk cancer, watchful waiting may be more appropriate than active surveillance.

• –Active treatment (radical prostatectomy (RP) or radiation therapy (RT)) is recommended for most patients with intermediate-risk (Gleason score 7) localized prostate cancer. For select patients with low-volume, intermediate-risk (Gleason score 3 + 4 =7) localized prostate cancer, AS may be offered.

• –The AS protocol should include the following tests:

  • PSA test every 3–6 mo.

  • Direct rectal exam at least once a year.

  • At least a 12-core confirmatory transrectal ultrasound-guided biopsy (including anterior-directed cores) within 6–12 mo and then serial biopsy every 2–5 y thereafter or more frequently if clinically warranted. Men with limited life expectancy may transition to watchful waiting and avoid further biopsies.

• –For patients undergoing AS who are reclassified to a high-risk category (Gleason score now 7 or greater and/or significant increase in volume of Gleason 6 tumor consideration) should be given active therapy (RP or RT).

Comments

1. There are other ancillary tests that may make a difference in deciding when definitive therapy is indicated. The multiparametric MRI (mpMRI) and genomic testing of the malignant prostate cancer may reveal larger tumor size or unfavorable mutations that put the patient in a higher risk category which will need definitive therapy.

2. Data at 10-y follow-up from both observational and randomized trials show a very similar survival, although patients on surveillance had an increase in frequency of metastatic disease and clinical progression. (N Engl J Med. 2016;375:1415)

3. This approach is especially beneficial to patients older than 65 who have comorbidities and higher risk of complications. Active surveillance also significantly avoids over-treatment and therapy-related morbidity. A recent 10-y follow-up comparing monitoring, surgery, and radiation therapy treatment outcomes resulted in very similar overall survival.

Sources

• –ASCO. J Clin Oncol. 2016;34:2182-2190.

• –N Engl J Med. 2016;375:1415.

• –N Engl J Med. 2014;370:932.

• –Eur Urol. 2015;67:233.

BENIGN PROSTATIC HYPERPLASIA (BPH)

Population

• –Adult men age >45 with lower urinary tract symptoms (LUTS) from prostatic enlargement.

Recommendations

AUA 2010

• –Routine measurement of serum creatinine is not indicated in men with BPH.

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