Defining Intermediate Risk Prostate Cancer Suitable for Active Surveillance.

Area of Science:

• Urology
• Oncology
• Prostate Cancer Research

Background:

• Active surveillance (AS) for prostate cancer (PCa) is debated, especially for intermediate-risk cases.
• Current AS programs often restrict eligibility to low-risk PCa (Grade Group 1, PSA < 10 ng/ml).
• Recent guidelines suggest considering AS for limited Grade Group 2 (Gleason 3+4) PCa, despite limited outcome data.

Purpose of the Study:

• To compare prostatectomy outcomes between intermediate-risk and low-risk prostate cancer subgroups.
• To evaluate the safety and feasibility of expanding active surveillance criteria for prostate cancer.

Main Methods:

• Observational study using the National Prostate Cancer Register of Sweden (2009-2016).
• Compared outcomes (upgrading, upstaging, adverse pathology) in 5,087 men with low-risk vs. intermediate-risk PCa.
• Validated findings using Cancer of the Prostate Risk Assessment (CAPRA) scores and published AS criteria.

Main Results:

• Men with Grade Group 1 PCa, PSA 10-15 ng/ml, and low PSA density (<0.15 ng/ml/cm) showed no significant increase in adverse pathology compared to low-risk PCa.
• PSA > 15 ng/ml or Grade Group 2 PCa significantly increased the risk of aggressive disease.
• Intermediate-risk men (CAPRA 0-2, Grade Group 2) had a 3x higher risk of upgrading and 2x higher risk of adverse pathology than low-risk men (CAPRA 0-2, Grade Group 1).

Conclusions:

• Expanding the PSA threshold to 15 ng/ml for Grade Group 1 PCa may allow more men to opt for active surveillance without compromising outcomes, especially with low PSA density.
• Active surveillance should be approached with caution in men with PSA > 15 ng/ml or Grade Group 2 PCa due to a higher risk of aggressive disease.