Active surveillance (AS) as a treatment option has been growing in popularity in recent years in Australia, enhanced by a growing collaboration between the Urological Society of Australia and New Zealand (USANZ) and the PRIAS project . Over recent years a Prostate Cancer Registry has identified that 36% of all low risk prostate cancers and 9% of intermediate risk cancers were being initially managed with AS.
In order for AS to be adopted safely one requires accurate initial classification of cancers, and that when progression occurs that all cases should theoretically remain curable. In order to determine the outcomes of AS in an Australian setting, a single-surgeon database was constructed in 2001, after appropriate ethics approval by Monash University.
92 men (32.8%) ceased AS. Of these 64.1% were due to disease (usually grade) progression on biopsy.
Of these 92 men who failed AS, 55 men underwent radical prostatectomy. Biopsy misclassification was common including under-staging of disease with pT3 disease or greater in 31% of men. Discordant index tumour location was identified in 44% of cases, and biopsy predicted the incorrect lobe in 16.4% of patients. Under-grading also was demonstrated in 35% of cases. Of those undergoing surgery PSA failure occurred in 12.7% of patients (2.5% of entire cohort) and all had successful salvage with radiotherapy. There have been no metastases seen, nor prostate cancer deaths.
We endeavoured to identify whether adding an additional 8 anteriorly directed needles to standard TRUS, or performing trans-perineal template biopsies (TPB) would improve classification.
85 men underwent re-biopsy using anterior TRUS technique; 28.2% had disease progression requiring treatment and of these 37.5% were found only in the anterior cores. Of the 55 men who underwent trans-perineal template biopsies ( TPB ) 22% had disease progression requiring treatment, and of these 58.3% were only found by the anterior cores of the TPB . Of those patients who progressed to radical prostatectomy up-grading was only seen in 6.6%, suggesting superior classification of men for AS with these techniques.
An area of future research is the role of MP MRI prostate in improving localisation and staging prior to re-biopsy for men on AS , and genomics and epigenetic markers in accurately identifying men with low risk features beyond Gleason grading .