Active surveillance in younger man with prostate cancer
At most centers strict age criteria lacking for eligibility for active surveillance of prostate cancer. Younger men are often counseled to undergo definitive treatment despite limited data on the outcomes of active surveillance in younger men.
In a retrospective study, the authors compared 417 men who began AS when they were younger than 60 years with 1667 who began AS at age 60 years or older. At a median follow-up of 6.2 years, the investigators found no significant difference in 5-year rates of biopsy progression-free survival in the younger and older men (83% in both), treatment-free survival (74% vs 71%), metastasis-free survival (99.7% vs 99%), or PCa-specific survival (100% vs 99.7%).
In the younger group, 131 men (31%) eventually underwent treatment, including for pathologic progression in 67% and PSA progression in 18%.
On multivariable analysis, 20% or greater involvement of any core on diagnostic biopsy and PSA density of 0.15 ng/mL2 or greater were associated with an approximately 2-fold increased risk of biopsy progression and progression to treatment, respectively.
AS is a safe and effective approach which spares any properly selected men younger than 60 years with low risk prostate cancer from intervention, provides adequate time for intervention if required, and shows durable disease specific survival.
Unfavorable measures of tumor volume, such as elevated PSA density, percent of positive cores, or percent of tumor involvement per core, are important factors to incorporate into shared decision making with patients since they may be harbingers of more aggressive disease that would benefit from definitive treatment.
Patients' median age in the younger and older groups was 55 and 69 years, respectively. At baseline, men in the younger-than-60 group generally had more favorable disease characteristics than men in the age 60 and older group. For example, the younger group had a significantly lower initial PSA level (4.6 vs 5.5 ng/mL) and had a significantly greater proportion of men with Grade Group 1 disease on initial biopsy (97.8% vs 90%) and with clinical stage T1 cancer (93.1% vs 86.3%).
The authors cited a previous study of younger men managed with AS at the University of California, San Francisco (UCSF), showing that 5-year treatment-free survival was similar for men aged 60 or less and older than 60 (65% vs 64%). In the UCSF study and a study of a cohort at Johns Hopkins University, younger age was associated with a lower risk of biopsy progression.
While such findings represent a substantial paradigm shift regarding the role of age in AS, these analyses further enforce the primary importance of tumor volume metrics such as PSA density and biopsy tumor involvement when risk stratifying patients eligible for active surveillance.
Salari K, Kuppermann D, Preston MA, et al. Active surveillance of prostate cancer is a viable option in men younger than 60 years. J Urol. 2019;201:1-7.