Identifying intermediate-risk candidates for active surveillance of prostate cancer
Identifying intermediate-risk candidates for active surveillance of prostate cancer
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DOI：
10.1016/j.urolonc.2017.06.048
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发表时间：
2017-10-01
影响因子：
2.7
通讯作者：
Goldenberg, S. Larry
中科院分区：
文献类型：
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作者：
Savdie, Richard;Aning, Jonathan;Goldenberg, S. Larry
目的：尽管已经建立了针对极低风险和低风险(LR)前列腺癌(PCA)的研究，但围绕向患有中等风险(IR)前列腺癌(IR)的男性提供主动监测(AS)仍存在争议。由于IR代表了广泛的疾病生物学，因此迫切需要定义资格标准，使患者和医生都能接受竞争风险的最佳平衡。材料和方法：在我们的AS队列中，男性根据国家综合癌症网络(NCCN有利和NCCN不利)和CAPRA分类被分配到风险类别。比较两组患者的临床、生化和病理特征、向明确的侵入性治疗的进展，以及随访活检的病理进展。结果：AS是651名男性患者的初始治疗方案，其中144人接受IR-PCA治疗。在中位随访时间为4.5年(范围0.6-19.1)期间，259名患者(39.7%)接受了明确治疗。此外，IR患者的5年和10年预测干预率分别为50%和66%。NCCN-LR组和NCCN-IR组的治疗率无差异，但CAPRA-IR组的治愈率高于CAPRA-LR组(P=0.025)。NCCN不利的IR患者接受明确干预的风险是有利的IR患者的两倍(危险比[HR]=2.07；95%CI：1.17~3.65；P=0.01)。在整个队列中，在多因素分析中，活检中心阳性(连续变量；P=0.006)和初次活检时ISUP分级2级或更高(P=0.027)是AS停止的独立预测因素。在中间组中，只有阳性活检核心的百分比是AS停止的独立预测因素(P=0.021)。仅1例IR患者发生转移性病变(0.7%)。5年和10年的总生存率分别为98.6%和94.1%。在18.7年和19.1年的随访中，有2例PCa死亡。结论：在所有AS中，核心参与百分比的增加和Gleason 4型的存在是进展风险增加的预测因素。对于IR患者，NCCN有利标准和CAPRA评分预测那些更有可能继续AS的患者。(C)2017 Elsevier Inc.保留所有权利。
Purpose: Although already established for very-low and low-risk (LR) prostate cancer (PCa), controversy remains around offering active surveillance (AS) to men with intermediate-risk (IR) PCa. As IR represents a broad spectrum of disease biology, there is a critical need to define eligibility criteria that will enable both patient and physician to accept AS as the best balance of competing risks. In this study, we aimed to identify predictors of progression to enable optimal patient selection.Materials and methods: In our AS cohort, men were assigned to risk categories according to the National Comprehensive Cancer Network (NCCN favorable and NCCN unfavorable) and the CAPRA classifications. Clinical, biochemical and pathological characteristics, progression to definitive invasive treatment, and pathologic progression on follow-up biopsies were compared among these groups. A multivariate Cox regression model was used to identify independent predictors of progression on AS.Results: AS was the initial management option for 651 men, including 144 with IR PCa. During the median follow-up of 4.5 years (range: 0.6-19.1), 259 patients (39.7%) underwent definitive treatment. Further, 5- and 10-year predicted rates of intervention for IR patients were 50% and 66%, respectively. Treatment rates were no different between the NCCN LR and NCCN IR groups, but were higher in CAPRA IR compared to CAPRA LR groups (P = 0.025). NCCN unfavorable IR patients had a twofold increased risk of definitive intervention compared to favorable IR (hazard ratio [HR] = 2.07; 95% CI: 1.17-3.65; P = 0.01). In the entire cohort, the percentage of biopsy cores positive (continuous variable; P = 0.006) and ISUP grade 2 or higher on initial biopsy (P = 0.027) were independent predictors of cessation of AS on multivariate analysis. In the intermediate group, only the percentage of positive biopsy cores was an independent predictor (P = 0.021) of AS cessation. Only 1 IR patient developed metastatic disease (0.7%). Actuarial overall survival at 5 and 10 years was 98.6% and 94.1%, respectively. There were 2 PCa deaths at 18.7 and 19.1 years of follow-up.Conclusion: In all AS, increasing percentage of core involvement and presence of Gleason pattern 4 are predictors of increased risk of progression. For IR patients, the NCCN favorable criteria and CAPRA score predict those more likely to remain on AS. (C) 2017 Elsevier Inc. All rights reserved.