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 side-effects 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 HugossonDept of Urology, Sahlgrenska Academy,

Göteborgs UniversitetSweden