Watchful Waiting and
Active surveillance for
low risk prostate carcinoma
Maurizio Brausi
Un programma di sorveglianza attiva e’ alla
portata di tutti i centri ?
EAU guidelines 2012: Indications
Active Surveillance: Follow-up
Patients who are in AS protocols should be
controlled periodically.
* PSA every 6 months
* Prostate Biopsy at 1-2 years
* MRI could be used instead prostate
biopsy ?
A Multisciplinary Approach To
Prostate Cancer
WHY A MULTIDISCIPLINARY MANAGEMENT OF CANCER ?
AIMS OF A MULTIDISCIPLINARY TEAM FOR CANCER
(Prostate Cancer Unit)
PROSTATE CANCER UNIT Ausl Modena
D: Un Programma di AS è alla portata di tutti i
Centri Ospedalieri ?
Risposta:
E’ alla portata della maggior parte dei centri
Ospedalieri che hanno la possibilità di controllare
i pazienti periodicamente e di eseguire biopsie
prostatiche in tempi adeguati.
L’approccio multidisciplinare dovrebbe essere
una priorità
In cosa un programma di AS differisce da un
programma di WW ?
EAU guidelines 2012: definizioni
EAU guidelines 2012:
WW in PC T1-2/N0/M0
EAU guidelines 2014: AS
EAU Guidelines 2014: AS
D: In cosa Differisce un programma di AS da
un programma di WW ?
Risposta
Un programma di AS prevede l’attento e
periodico monitoraggio del paziente (ogni 6 mesi
con PSA) e controllo della prostata con biopsia
ogni 1-2 anni.
Un programma di WW non prevede controlli
periodici e tratta il paziente alla presenza di
eventuali sintomi.
Risks of Active Surveillance
Protocols
Active Surveillance
It is not a strategy for everyone with low risk PC but
should be one option or probably the first option.
It is not a passive approach
The primary goal is not to decrease overtreatment but
to maximize the quality of life on an individual basis
Active Surveillance
One should not treat PC as early as possible but
as late as possible while still curable with low
morbidity
Overtreatment is not only associated to negative
impact on Quality of Life but is also very costly
Side-effects from treatment
Permanent side-effects from treatment are
common and results in lowered quality of life!!
Side-effects are significantly lower if treated by
the most skilful surgeons in high volume
centers, but how is it on an average?
Patient Selection For AS
Variable, according to different International
protocols:
1-2 core of Pca Gleason score 3+3 < 15% in the core at
standard biopsy
Different Methods of diagnosis: If we use standard (12
cores Biopsy) we miss about 30-35% of significant
cancer (Gleason score 7). This was studied by a group
who performed Template biopsy in patients on AS
selected with standard biopsy
Selecting Patients For AS
Multiparametric MRI (3 Tesla) with targeted biopsy
will be the future (US Fusion)
The standard in 2013 for diagnosis and patient
selection AS is Template biopsy
5 deaths in PC but only one
was low risk
60 % of all screen-detected cancers were of low risk
Failure rate measured as tumor recurrence after active treatment
(PSA relapse or hormonal treatment)
What is the problem with AS
Close and life long FU contribute to stigmatise the
patient
Knowing having PC may cause psychological trauma
which in certain individuals may burden the quality
of life more than side effects from treatment
We have no validated trigger points for switching to
active treatment
Treating men after progression may cause more sideeffects than treating men early
Conclusions
Low risk PC is low risk, but be careful some are falsely
staged, early re-evaluation!!
The overwhelming majority of men with low risk PC will
never develop symptoms and will die from other causes
AS with delayed active treatment in those who need seem
to be as effective as treating all actively from start
Existing active treatments that are evidence based are
associated with side-effects that will considerably affect
quality of life in many patients
Surveillance will maximise quality of life and reduce costs
Future Goals
Find strategies to avoid diagnosing insignificant
low risk PC
Better screening tools for detecting biologically
significant cancers
Biopsy men more selectively and change from
systematic to imaging guided biopsies
What is the risk with low risk PC?
Rider et al Eur Urol 2012
Popiolek et al Eur Urol 2012
Klotz et al JCO 2010
Godtman et al Eur Urol 2012
To undertreat patients who will progress and
develop metastatic disease
Pro Surveillance
Jonas Hugosson
Dept of Urology, Sahlgrenska Academy,
Göteborgs Universitet
Sweden