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MP69-16 ACTIVE SURVEILLANCE FOR PROSTATE CANCER: RETHINKING PROSTATE-SPECIFIC ANTIGEN DENSITY ELIGIBILITY CRITERIA
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Tuesday, May 20, 2014
However, no differences were observed in the BCR-free survival rates when patients with organ-confined disease and pathological Gleason score 6 (Group 1) were compared to those with organ-confined disease and pathological Gleason score 3+4 (Group 2; P¼0.4). CONCLUSIONS: Roughly a quarter of men of potential AS candidates harbors unfavorable disease at final pathology. While non organ confined and or Gleason score 4+3 patients had worse cancer control after RP, the upgrade from biopsy Gleason score 6 to pathological Gleason score 3+4 does not significantly increase the risk of BCR. Active therapy may be thus consider an overtreatment also in these men despite higher Gleason score (3+4). This may suggest the potential inclusion also of these men in prospective AS protocols. Source of Funding: none
MP69-16 ACTIVE SURVEILLANCE FOR PROSTATE CANCER: RETHINKING PROSTATE-SPECIFIC ANTIGEN DENSITY ELIGIBILITY CRITERIA Yunsok Ha, Cheongju, Korea, Republic of; Neal Patel*, Amirali Salmasi, Eric Singer, New Brunswick, NJ; Jihyeong Yu, Seoul, Korea, Republic of; Jeong Hyun Kim, Chuncheon, Korea, Republic of; Wun-Jae Kim, Cheongju, Korea, Republic of; Isaac Yi Kim, New Brunswick, NJ INTRODUCTION AND OBJECTIVES: Active surveillance (AS) is an acceptable treatment option for low risk prostate cancer (PCa). However, optimal criteria for patient selection, surveillance strategies, and intervention thresholds are controversial. Furthermore, the inaccuracy in clinical staging raises concern about mismanagement of men with PCa on AS. Recently reported data supports the hypothesis that prostate-specific antigen density PSAD is a more accurate preoperative predictor of Gleason score (GS) upgrading than PSA. We investigatd the effect of PSAD on existing prostate cancer (CaP) active surveillance (AS) selection criteria. METHODS: A prospectively maintained database of men who underwent robotic assisted radical prostatectomy (RARP) at Rutgers Cancer Institute of New Jersey between January 2006 and May 2013 was analyzed retrospectively. Demographic data and pathologic characteristics of patients who fulfilled AS inclusion criteria under Johns Hopkins Medical Institution (JHMI) criteria and Prostate Cancer Research International Active Surveillance (PRIAS) criteria were examined. After RARP, the rate of pathological upstaging, GS upgrading, and biochemical recurrence were evaluated. RESULTS: Of 930 patients with PCa who underwent RARP, 231 (24.8%) and 280 (30.1%) men fulfilled the AS criteria of JHMI and PRIAS, respectively. The frequencies of advanced disease on surgical pathology (upstaging and/or upgrading) were 31.6% (JHMI) and 35.4% (PRIAS) of study cohorts. PSAD was significantly higher in patients with advanced disease compared to PSAD in men with non-advanced disease in both AS schema (0.103 0.029 vs. 0.088 0.031 in JHMI and 0.110 0.038 vs. 0.092 0.037 in PRIAS, both P< 0.05). The optimal PSAD cutoff level for the prediction of advanced disease was 0.085 ng/ ml2 (sensitivity 76.7%, specificity 50.6% in JHMI and sensitivity 75.6%, specificity 49.7% in PRIAS). Using this cutoff value, a higher PSAD level was an independent predictor of advanced disease using multivariate logistic regression analyses in both criteria. CONCLUSIONS: Among patients with very low risk PCa based on JHMI and PRIAS AS criteria who underwent RARP, PSAD is a predictor of advanced disease at the time of surgery. A lower PSAD value may be warranted to improve AS selection criteria. Source of Funding: None.
MP69-17 OUTCOMES FOLLOWING REPEAT PROSTATE BIOPSY FOR ATYPICAL SMALL ACINAR PROLIFERATION Jeffrey Tomasini*, Michael Risk, Kendall Feia, Bruce Lindgren, Carlos Iwamoto, Christopher Warlick, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Recommendations suggest repeat prostate biopsy after atypical small acinar proliferation
e821
(ASAP) is diagnosed given cancer detection rates up to 60% in some series. Little is known about the clinical significance of these cases. With increasing concern of overdiagnosis and overtreatment of prostate cancer, we examined the outcomes of patients re-biopsied for a diagnosis of ASAP at our institutions. METHODS: A retrospective chart review identified patients with ASAP on prostate biopsy at the Minneapolis VA and University of Minnesota Medical Centers from 2000-2010. Patients with a prior diagnosis of prostate cancer were excluded. Statistical analyses included Fisher’s exact and the two-sample Wilcoxon rank sum tests. Logistic regression evaluated risk factors for the probability of cancer following ASAP. RESULTS: A combined 349 patients from both institutions met inclusion criteria with mean follow-up of 4.9 years. Mean age was 65.3 years and median PSA of 5.3 ng/mL. Of all men diagnosed with ASAP, 250/349 (71%) had a repeat biopsy within 1 year. A total of 94/246 (38%) had prostate cancer on repeat biopsy, while only 26/246 (11%) had Gleason 7 disease. Of all men with ASAP, 284/349 (81%) underwent biopsy during follow-up. Prostate cancer was diagnosed in 132/ 279 (47%), and 48/279 (17%) had Gleason 7 disease. Men with no prior negative biopsies before ASAP compared to those with 1-3 prior biopsies were more likely to be diagnosed with cancer on re-biopsy within one year (41% vs. 24%; p¼0.030) or at any time (50% vs. 34%; p¼0.038). Multivariate analyses suggest that older age, no prior negative biopsy, and greater PSA density were predictive of cancer on repeat biopsy within 1 year from ASAP, while these factors in addition to family history were predictive of a diagnosis of cancer at any time after diagnosis of ASAP. Of all men diagnosed with prostate cancer after ASAP, 78% had definitive therapy. CONCLUSIONS: There is a low rate of Gleason 7 or higher prostate cancer on immediate re-biopsy following a diagnosis of ASAP. Age, family history, and PSA density may be useful to determine those more likely to be diagnosed with prostate cancer. Given the low rate of intermediate and high grade prostate cancer on repeat biopsy, close surveillance rather than immediate re-biopsy may be an alternative management strategy for appropriately selected men. Source of Funding: None
MP69-18 HOW TO EXPAND INDICATIONS FOR ACTIVE SURVEILLANCE WITHOUT COMPROMISING CANCER CONTROL: A SYSTEMATIC ASSESSMENT OF THE CURRENTLY USED CRITERIA FOR PROSTATE CANCER PATIENTS Umberto Capitanio*, Firas Abdollah, Andrea Gallina, Marco Bianchi, Vito Cucchiara, Nazareno Suardi, Milan, Italy; Vincenzo Mirone, Naples, Italy; Rocco Damiano, Francesco Cantiello, Catanzaro, Italy; Pierre I. Karakiewicz, Maxine Sun, Montreal, Canada; Shahrokh F. Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: Several inclusion criteria have been proposed to enrol prostate cancer (PCa) patients in active surveillance (AS) protocols. However, such criteria may be too stringent and challenging to be applicable in clinical practice, with few patients that can be actually recruited. We assessed the ability of each clinical predictor in selecting potential candidates for AS. METHODS: We included 2,077 PCa patients with complete preoperative data treated with radical prostatectomy and pelvic lymph node dissection at a single Tertiary Care Institution between 2008 and 2013. We calculated the number of patients who could be candidate for AS according to the criteria proposed by Van De Bergh (PSA 10 ng/ml, PSA density <0.2 ng/ml/cc, biopsy Gleason score (GS)¼6, positive biopsy cores 2, clinical stage T2) and according to all combinations of each criterion. Moreover, we calculated the prevalence of unfavourable disease (UD), defined as presence of ECE or SVI or LNI or pathological GS 7-10) when each combination was used. Finally, ROC curve analyses were
Vol. 191, No. 4S, Supplement, Tuesday, May 20, 2014
However, no differences were observed in the BCR-free survival rates when patients with organ-confined disease and pathological Gleason score 6 (Group 1) were compared to those with organ-confined disease and pathological Gleason score 3+4 (Group 2; P¼0.4). CONCLUSIONS: Roughly a quarter of men of potential AS candidates harbors unfavorable disease at final pathology. While non organ confined and or Gleason score 4+3 patients had worse cancer control after RP, the upgrade from biopsy Gleason score 6 to pathological Gleason score 3+4 does not significantly increase the risk of BCR. Active therapy may be thus consider an overtreatment also in these men despite higher Gleason score (3+4). This may suggest the potential inclusion also of these men in prospective AS protocols. Source of Funding: none
MP69-16 ACTIVE SURVEILLANCE FOR PROSTATE CANCER: RETHINKING PROSTATE-SPECIFIC ANTIGEN DENSITY ELIGIBILITY CRITERIA Yunsok Ha, Cheongju, Korea, Republic of; Neal Patel*, Amirali Salmasi, Eric Singer, New Brunswick, NJ; Jihyeong Yu, Seoul, Korea, Republic of; Jeong Hyun Kim, Chuncheon, Korea, Republic of; Wun-Jae Kim, Cheongju, Korea, Republic of; Isaac Yi Kim, New Brunswick, NJ INTRODUCTION AND OBJECTIVES: Active surveillance (AS) is an acceptable treatment option for low risk prostate cancer (PCa). However, optimal criteria for patient selection, surveillance strategies, and intervention thresholds are controversial. Furthermore, the inaccuracy in clinical staging raises concern about mismanagement of men with PCa on AS. Recently reported data supports the hypothesis that prostate-specific antigen density PSAD is a more accurate preoperative predictor of Gleason score (GS) upgrading than PSA. We investigatd the effect of PSAD on existing prostate cancer (CaP) active surveillance (AS) selection criteria. METHODS: A prospectively maintained database of men who underwent robotic assisted radical prostatectomy (RARP) at Rutgers Cancer Institute of New Jersey between January 2006 and May 2013 was analyzed retrospectively. Demographic data and pathologic characteristics of patients who fulfilled AS inclusion criteria under Johns Hopkins Medical Institution (JHMI) criteria and Prostate Cancer Research International Active Surveillance (PRIAS) criteria were examined. After RARP, the rate of pathological upstaging, GS upgrading, and biochemical recurrence were evaluated. RESULTS: Of 930 patients with PCa who underwent RARP, 231 (24.8%) and 280 (30.1%) men fulfilled the AS criteria of JHMI and PRIAS, respectively. The frequencies of advanced disease on surgical pathology (upstaging and/or upgrading) were 31.6% (JHMI) and 35.4% (PRIAS) of study cohorts. PSAD was significantly higher in patients with advanced disease compared to PSAD in men with non-advanced disease in both AS schema (0.103 0.029 vs. 0.088 0.031 in JHMI and 0.110 0.038 vs. 0.092 0.037 in PRIAS, both P< 0.05). The optimal PSAD cutoff level for the prediction of advanced disease was 0.085 ng/ ml2 (sensitivity 76.7%, specificity 50.6% in JHMI and sensitivity 75.6%, specificity 49.7% in PRIAS). Using this cutoff value, a higher PSAD level was an independent predictor of advanced disease using multivariate logistic regression analyses in both criteria. CONCLUSIONS: Among patients with very low risk PCa based on JHMI and PRIAS AS criteria who underwent RARP, PSAD is a predictor of advanced disease at the time of surgery. A lower PSAD value may be warranted to improve AS selection criteria. Source of Funding: None.
MP69-17 OUTCOMES FOLLOWING REPEAT PROSTATE BIOPSY FOR ATYPICAL SMALL ACINAR PROLIFERATION Jeffrey Tomasini*, Michael Risk, Kendall Feia, Bruce Lindgren, Carlos Iwamoto, Christopher Warlick, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Recommendations suggest repeat prostate biopsy after atypical small acinar proliferation
e821
(ASAP) is diagnosed given cancer detection rates up to 60% in some series. Little is known about the clinical significance of these cases. With increasing concern of overdiagnosis and overtreatment of prostate cancer, we examined the outcomes of patients re-biopsied for a diagnosis of ASAP at our institutions. METHODS: A retrospective chart review identified patients with ASAP on prostate biopsy at the Minneapolis VA and University of Minnesota Medical Centers from 2000-2010. Patients with a prior diagnosis of prostate cancer were excluded. Statistical analyses included Fisher’s exact and the two-sample Wilcoxon rank sum tests. Logistic regression evaluated risk factors for the probability of cancer following ASAP. RESULTS: A combined 349 patients from both institutions met inclusion criteria with mean follow-up of 4.9 years. Mean age was 65.3 years and median PSA of 5.3 ng/mL. Of all men diagnosed with ASAP, 250/349 (71%) had a repeat biopsy within 1 year. A total of 94/246 (38%) had prostate cancer on repeat biopsy, while only 26/246 (11%) had Gleason 7 disease. Of all men with ASAP, 284/349 (81%) underwent biopsy during follow-up. Prostate cancer was diagnosed in 132/ 279 (47%), and 48/279 (17%) had Gleason 7 disease. Men with no prior negative biopsies before ASAP compared to those with 1-3 prior biopsies were more likely to be diagnosed with cancer on re-biopsy within one year (41% vs. 24%; p¼0.030) or at any time (50% vs. 34%; p¼0.038). Multivariate analyses suggest that older age, no prior negative biopsy, and greater PSA density were predictive of cancer on repeat biopsy within 1 year from ASAP, while these factors in addition to family history were predictive of a diagnosis of cancer at any time after diagnosis of ASAP. Of all men diagnosed with prostate cancer after ASAP, 78% had definitive therapy. CONCLUSIONS: There is a low rate of Gleason 7 or higher prostate cancer on immediate re-biopsy following a diagnosis of ASAP. Age, family history, and PSA density may be useful to determine those more likely to be diagnosed with prostate cancer. Given the low rate of intermediate and high grade prostate cancer on repeat biopsy, close surveillance rather than immediate re-biopsy may be an alternative management strategy for appropriately selected men. Source of Funding: None
MP69-18 HOW TO EXPAND INDICATIONS FOR ACTIVE SURVEILLANCE WITHOUT COMPROMISING CANCER CONTROL: A SYSTEMATIC ASSESSMENT OF THE CURRENTLY USED CRITERIA FOR PROSTATE CANCER PATIENTS Umberto Capitanio*, Firas Abdollah, Andrea Gallina, Marco Bianchi, Vito Cucchiara, Nazareno Suardi, Milan, Italy; Vincenzo Mirone, Naples, Italy; Rocco Damiano, Francesco Cantiello, Catanzaro, Italy; Pierre I. Karakiewicz, Maxine Sun, Montreal, Canada; Shahrokh F. Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: Several inclusion criteria have been proposed to enrol prostate cancer (PCa) patients in active surveillance (AS) protocols. However, such criteria may be too stringent and challenging to be applicable in clinical practice, with few patients that can be actually recruited. We assessed the ability of each clinical predictor in selecting potential candidates for AS. METHODS: We included 2,077 PCa patients with complete preoperative data treated with radical prostatectomy and pelvic lymph node dissection at a single Tertiary Care Institution between 2008 and 2013. We calculated the number of patients who could be candidate for AS according to the criteria proposed by Van De Bergh (PSA 10 ng/ml, PSA density <0.2 ng/ml/cc, biopsy Gleason score (GS)¼6, positive biopsy cores 2, clinical stage T2) and according to all combinations of each criterion. Moreover, we calculated the prevalence of unfavourable disease (UD), defined as presence of ECE or SVI or LNI or pathological GS 7-10) when each combination was used. Finally, ROC curve analyses were