Active Surveillance May Increase Likelihood of Adverse Outcomes in Low-Volume Intermediate-Risk Prostate Cancer

Active Surveillance May Increase Likelihood of Adverse Outcomes in Low-Volume Intermediate-Risk Prostate Cancer

Active surveillance may expose men with intermediate-risk prostate cancer to adverse outcomes that could be avoided by immediate intervention, according to the findings of a large cohort study.

The study, “Adverse Pathologic Findings for Men Electing Immediate Radical Prostatectomy,” was published in the journal JAMA Oncology.

Active surveillance is currently recommended to patients with very-low-risk (VLR) and low-risk (LR) prostate cancer. But more recent clinical guidelines have suggested that active surveillance also may be considered in men with low-volume intermediate-risk (LVIR) disease, a decision that remains controversial.

In active surveillance, patients do not undergo immediate radical treatment, which includes surgery or radiation therapy. Instead, they are monitored carefully over time for signs of disease progression.

Now, researchers at Johns Hopkins University School of Medicine performed a retrospective cohort study and compared the rate of signs of disease among VLR, LR, and LVIR men undergoing radical prostatectomy and evaluated retrospectively at Johns Hopkins Hospital.

Specifically, researchers asked, “Is there a subset of men with Gleason 3+4=7 intermediate-risk prostate cancer with favorable characteristics to minimize risk of adverse pathologic findings at surgery?”

In total, the study included 1,264 men with clinically localized VLR, 4,849 with LR, and 608 with LVIR, as defined by National Comprehensive Cancer Center (NCCN) criteria.

Researchers found that the rate of adverse pathologic findings was significantly higher for LVIR disease when compared to those with LR or VLR disease, at 24.7%, 5.8%, and 4.7%, respectively.

This means that men with LVIR had almost a 4.5-fold increase in the risk of adverse pathologic findings compared with men who had LR disease, and a 5.2-fold increase compared with men with VLR disease.

According to current NCCN guidelines, some LVIR patients may consider active surveillance, but the practice is controversial.

“Our observations suggest use of active surveillance may place similar men with Gleason 3+4=7 (GG2) cancer at risk of adverse outcomes that could have potentially been avoided with immediate intervention. This study could have important implications for men with LVIR prostate cancer electing [active surveillance], and further study is clearly needed,” researchers wrote.

In an attempt to stratify the risk of the LVIR group, researchers analyzed both preoperative clinical and pathologic criteria. However, none of these could define a favorable subgroup within the LVIR group with a rate of adverse pathologic findings as low as those of VLR and LR patients.

Overall, these results do not support the presence of a “favorable” subgroup among men with intermediate-risk prostate cancer.

“Men with Gleason 3+4=7 prostate cancer otherwise eligible for curative intervention should be fully informed as to the avoidable risk associated with use of active surveillance,” the study concluded.


  1. Lawrence Glickman says:

    Just for the record I have posted my opinion before. “Active Surveillance” is too me a very poor strategy. Ask your Doctor if he can guarantee that during this time period that there will not be metastases to the bones or a vital organ? He will probably quote statistics as his reasoning. Next ask him why is prostate cancer the one form of cancer where early treatment is not recommended? Next ask him, Is it true that a single cell of prostate cancer that escapes the organ can show up later as remote tumors and a slow death sentence? I’m not being dramatic, this is a fact. Statistics are not human beings and using them as means of calming a scared patient out of early treatment is nothing more than playing Russian roulette with the life of that patient. Having helped many of my friends in this area I can only report that one of my friends ignored this advice when he was first diagnosed and waited a year and later had only radical surgery as an option. He survived the surgery and so far so good but he now has potency problems etc which are quite common with this type of treatment. My advice is simple, better safe than sorry later. Get treatment while the opportunity of a cure is at its most available.

    • ASAdvocate says:

      I’ve been on active surveillance for eight years, with no progression in my pathology. In fact, my last biopsy was negative. Are you trying to tell me that a VLR patient like myself should be overtreated and suffer serious quality of life issues because you say so? No way!

      • Lawrence Glickman says:

        I wish you all the best. In “Russian Roulette” 5 of the 6 chambers are empty and therefore the odds are in your favor when you spin the wheel. But drop longer you spin it. In addition you currently have no idea if your gamble is really paying off as there are ZERO reliable tests for small metastases at the moment except for a few expensive new chemical tests. So your if PSA is your only guideline it will not capture metastases until they have possibly left organ confinement. In addition the main reason men hold off is sexual potency fears and these men are almost always ignorant of the many new less invasive treatments such as focal Cryo,(Freezing)(Dr. Duke Bahn) toocad (Recent Sloan Kettering positive trial), focal Hifu, and many others with an excellent record of potency maintenance as the procedures are designed to destroy localized lesions. These options will not be available if the Prostate enclosure is compromised. At that point your prognosis is usually grave and side effects much more serious. You should at least look into the new Polaris test for aggressiveness of your cancer and the new 3T MRI scans which are more accurate than the older models of MRI.

  2. Edward Speaks says:

    One month active surveillance is the order of the day for low-risk patients. This in order to avoid unnecessary operations or radiation, both of which can cause quality of life issues. The next month it’s an absolute must to have an operation/radiation immediately after a conclusion of low-risk prostate cancer. One of the more frustrating parts of prostate cancer is the constant contradictions of treatments. Please medicos, which is it?

  3. ASAdvocate says:

    There is nothing new here. AS is not being questioned for VLR and LR men. The issue here is about intermediate risk men trying AS. The results haven’t met expectations, I think that over 20 percent had subsequent adverse pathologies. So, active surveillance is probably not recommended for guys above low risk. There seems to be a remaining question if the intermediate risk cases could be further analyzed to sort out the ones who could be successful? Until then, it’s risky for men above LR criteria.

  4. Michael J Madrid says:

    In totaal agreement with Edward Speaks that there are total contradictions in opinions of doctors with some not giving considerarion to quality of life issues, which to the patient is extremely important. Also, will some one tell these archaic doctors you do a MRI first before a biopsy because if you do a biopsy first, the MRI is compromised because the organ is bruised, bloodied and inflamed and the MRI is not worth a damn to determine staging.Common sense.

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