Active Surveillance for Low- and Favourable Intermediate-Risk Prostate Cancer: A Single-Centre Cohort Study on Discontinuation Rates and Quality-of-Life Outcomes
Aug 2026· Journal of Personalized Medicine· Vol 16, pp. 420· 0 citations· 27 references
Medicine
TL;DR
In this single-centre cohort, AS discontinuation occurred early and at a rate higher than that of established international programmes, consistent with the institution’s initial AS experience.
Abstract
Background: Active surveillance (AS) represents a cornerstone of personalized medicine in uro-oncology, offering an individualized management strategy for low- and selected favourable intermediate-risk prostate cancer that aligns treatment intensity with patient-specific risk profiles; however, real-world adherence data from southern European academic centres remain scarce. This study aimed to evaluate AS discontinuation rates, reasons for transition to active treatment, and quality of life (QoL) in a single-centre Greek university hospital cohort. Methods: This is an observational retropective cohort study of patients enrolled in an AS protocol at the First Department of Urology, Aristotle University of Thessaloniki, between October 2016 and July 2022. Treatment-free survival (TFS) was estimated using Kaplan–Meier analysis. Associations between AS discontinuation and age at diagnosis, PSA level, and Charlson Comorbidity Index (CCI) were explored using univariable and multivariable Cox proportional hazards regression. QoL, erectile function, and anxiety were assessed cross-sectionally in patients remaining on AS using SF-12, IIEF-6, STAI-6, and MAX-PC. Results: Thirty-six patients were included (32 low-risk; 4 favourable intermediate-risk), with a median age of 69.5 years, median PSA of 6.92 ng/mL, and median CCI of 3. After a median follow-up of 24 months (IQR 21–45), 19 patients (52.8%) transitioned to active treatment; the median time to treatment was 21 months (IQR 17–34). Among the 10 patients with a known reason for discontinuation, 6 (31.6% of all discontinued) showed histopathological or clinical disease progression, 3 (15.8%) had a PSA increase alone, and 1 (5.3%) transitioned due to urinary symptoms; the reason was unknown in 9 cases (47.4%). In exploratory Cox regression, PSA ≥ 7.0 ng/mL was the only factor with complete documented output significantly associated with transition to active treatment (univariable HR 3.70, 95% CI 1.35–10.1, p = 0.011; multivariable HR 3.93, 95% CI 1.42–10.9, p = 0.008). Cross-sectional QoL assessment in 10 patients remaining on AS demonstrated median scores above established population norms for SF-12 and below clinical anxiety thresholds on STAI-6 and MAX-PC. Conclusions: In this single-centre cohort, AS discontinuation occurred early and at a rate higher than that of established international programmes, consistent with the institution’s initial AS experience. Higher PSA at diagnosis was the only factor with complete analytical documentation to be significantly associated with earlier transition.
A model using simple, routine parameters and PSA doubling time can identify those at minimal risk of reclassification, enabling a safe reduction in biopsy intensity, and advocates for a risk-adaptive AS protocol.
C. Marenghi, F. Badenchini, B. Avuzzi et al.· Tumori· 0 citations
Growing evidence suggests that AS appears oncologically safe in well-selected patients, and magnetic resonance imaging will play a key role in the appropriate selection and follow-up of patients.
Alessandro Uleri, L. Cella, T. Long-Depaquit et al.· BJU International· 0 citations
Background/Objectives: Prostate cancer is biologically heterogeneous, and prognostic stratification informs the choice between definitive treatment and conservative management. Most evidence on the Gleason score addresses prostate cancer-specific mortality rather than survival from any cause. We assessed the association between Gleason score category and overall survival in a contemporary population-based cohort. Methods: Using Surveillance, Epidemiology, and End Results (SEER) Research Data from 17 registries (November 2024 submission), we included men aged 40 years and older with a first primary malignant prostate cancer and a recorded Gleason Score Clinical Recode (2010+). Because this recode is undefined before 2010, the analytic period was 2010–2019. Gleason score was categorized as ≤6, 7, and ≥8. Overall survival was estimated by Kaplan–Meier methods and compared by log-rank test; multivariable Cox regression adjusted for age, race and ethnicity, marital status, summary stage, surgery at the primary site, radiation therapy, and chemotherapy, with localized disease as the stage reference. Results: Among 374,763 men, 145,668 (38.9%) had Gleason ≤ 6, 148,773 (39.7%) Gleason 7, and 80,322 (21.4%) Gleason ≥ 8, with mortality during follow-up of 11.3%, 14.6% and 36.6% respectively (log-rank p < 0.0001). Adjusted hazards of death were higher for Gleason 7 (HR 1.53, 95% CI 1.50–1.57) and Gleason ≥ 8 (HR 2.89, 95% CI 2.82–2.95) relative to Gleason ≤ 6. Advancing age, regional disease (HR 1.47, 95% CI 1.43–1.51) and distant disease (HR 3.74, 95% CI 3.65–3.84) were also associated with increased mortality. The grade association attenuated over follow-up, the hazard ratio for Gleason ≥ 8 falling from 4.12 within two years to 2.17 beyond five years. Conclusions: Gleason score category is independently associated with overall survival and retains prognostic value on the all-cause mortality scale, with greatest discrimination in the years immediately following diagnosis.
Purpose Active surveillance (AS) is an established management strategy for favorable-risk prostate cancer (PCa). In real-world practice, decisions to continue AS or active treatment (AT) are influenced by both disease-related and patient-related factors. This study aimed to identify factors associated with the transition from AS to AT in a large multicenter cohort. Materials and Methods We analyzed 716 patients with PCa managed with AS across 12 institutions. Baseline clinical characteristics, comorbidity burden assessed via the Charlson comorbidity index (CCI), performance status evaluated using the Eastern Cooperative Oncology Group (ECOG) score, and disease-related factors, including prostate-specific antigen (PSA), PSA density (PSAD), and magnetic resonance imaging findings, were collected. Cox proportional hazards regression was used to identify factors associated with conversion to AT. Results During a mean follow-up of 28.4 months, 224 patients (31.3%) transitioned from AS to AT, most frequently because of pathologic reclassification (60.3%). In multivariate analysis, maximum core involvement (hazard ratio [HR] 1.015, p=0.003) and PSAD ≥0.10 ng/mL/cm3 (HR 1.478, p=0.044) were independently associated with conversion to AT. Although ECOG performance status and CCI were not statistically significant in multivariate models, patients with poorer functional status or greater comorbidity burden remained on AS rather than proceeding to AT. Conclusions In this large multicenter study, PSAD was the strongest predictor of transition to AT during AS for PCa. Beyond disease-related factors, patient condition also appeared to influence real-world decisions about continuing AS.
Joongwon Choi, Chung-Un Lee, S. Jeon et al.· Investigative and Clinical U...· 0 citations
The shift towards more selective use of preoperative radiotherapy in rectal cancer raises concern that locoregional control may be compromised. The aim was to evaluate whether changes in staging, risk stratification, and treatment across three national guideline periods were associated with differences in oncological outcomes in patients with clinical stage I–III rectal cancer treated with curative intent.
2035 patients from Dalarna, Gävleborg, and Uppsala County with clinical stage I-III rectal cancer were included. Data were obtained from the Swedish Colorectal Cancer Registry and supplemented by review of electronic patient records. Logistic regression with guideline period modelled as an ordinal variable was used to assess differences in treatment over time. Associations between guideline period and oncological outcomes were analysed using unadjusted and adjusted Cox and Fine-Gray models.
The proportion of patients staged as cN0 increased over time (OR per period 1.40, 95% c.i. 1.25–1.56), whereas the proportion of patients with cN2 decreased (OR 0.67, 95% c.i. 0.59–0.76). Direct surgery increased (26, 33, and 43%), while overall preoperative treatment (44, 40, and 31%) and short-course radiotherapy (35, 27, 12%) decreased over time.
Locoregional recurrence was 3.1% at 5 years and did not differ between guideline periods. No differences were observed in distant metastasis, overall survival, or relative survival after adjustment, although unadjusted analyses suggested lower distant metastasis rates in the most recent period.
Reduced use of preoperative radiotherapy was not associated with impaired oncological outcomes. The findings support a more selective radiotherapy use while maintaining oncological safety and reducing treatment-related morbidity.
S. Doroudian, E. Osterman, B. Glimelius· British Journal of Surgery· 0 citations
INTRODUCTION
Focal therapy (FT) in high-risk or very high-risk prostate cancer (CaP) is not guideline-recommended. However, it may be occasionally used, but its effect on cancer-specific mortality (CSM) relative to standard treatment options such as radical prostatectomy (RP) is unknown and was addressed in the present study.
METHODS
In the Surveillance, Epidemiology, and End Results (SEER) database (2010-2022), high-risk or very high-risk CaP patients according to the National Comprehensive Cancer Network (NCCN) guidelines, treated with either FT or RP, were identified. A multivariable logistic regression (MLR) model assessed the associations between sociodemographic characteristics and receipt of FT. Multivariable competing risks regression (CRR) models, after 1:1 propensity score matching (PSM), tested for CSM differences after adjustment for other cause mortality (OCM).
RESULTS
Overall, 20,192 high-risk or very high-risk CaP patients treated with FT or RP were identified. Of those, 416 (2.0%) underwent FT and 19,776 (98.0%) RP. In the MLR model, rural area of residence and unmarried status predicted a 2.4-fold (P < 0.001) and 1.8-fold (P < 0.001) higher likelihood of receiving FT, respectively. In PSM analysis, 416 FT patients could only be matched with one RP control from 19,776 RP patients. After 1:1 PSM, at 120 months of follow-up, CSM after RP was 9.2 vs. 16.0% after FT. The corresponding OCM rates were 19.5 after RP vs. 31.5% after FT. In multivariable CRR models adjusted for OCM, FT increased CSM in a 2.0-fold fashion (mHR: 1.98; 95% CI: 1.17-3.34; P = 0.011).
CONCLUSION
Despite lack of guidelines endorsement, occasional high-risk or very high-risk CaP patients may be treated with FT. Specifically, rural and unmarried patients with high-risk or very high-risk CaP are more likely to receive guideline-discordant FT. Such practice doubles the risk of CSM relative to RP, and its use should therefore be discouraged in this patient population.
L. Quarta, M. Petix, M. Filzmayer et al.· Urologic oncology· 0 citations
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