The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH 12000 McCracken Road, Cleveland, OH 44125, USA.
Eur Urol Focus. 2022 Sep;8(5):1141-1150. doi: 10.1016/j.euf.2021.07.003. Epub 2021 Jul 31.
For men on active surveillance (AS) for prostate cancer (PCa), disease progression and age-related changes in health may influence decisions about pursuing curative treatment.
To evaluate the predicted PCa and non-PCa mortality at the time of reclassification among men on AS, to identify clinical criteria for considering a transition from AS to watchful waiting (WW).
DESIGN, SETTING, AND PARTICIPANTS: Patients enrolled in a large AS program who experienced biopsy grade reclassification (Gleason grade increase) were retrospectively examined. All patients who had complete documentation of medical comorbidities at reclassification were included.
A validated model was used to assess 10- and 15-yr untreated PCa and non-PCa mortalities based on patient comorbidities and PCa clinical characteristics. We compared the ratio of predicted PCa mortality with predicted non-PCa mortality ("predicted mortality ratio") and divided patients into four risk tiers based on this ratio: (1) tier 1 (ratio: >0.33), (2) tier 2 (ratio 0.33-0.20), (3) tier 3 (ratio 0.20-0.10), and (4) tier 4 (ratio <0.10).
Of the 344 men who were reclassified, 98 (28%) were in risk tier 1, 85 (25%) in tier 2, 93 (27%) in tier 3, and 68 (20%) in tier 4 for 10-yr mortality. Fifteen-year risk tiers were distributed similarly. The 23 (6.7%) men who met the "transition triad" (age >75 yr, Charlson Comorbidity Index >3, and grade group ≤2) had a 14-fold higher non-PCa mortality risk and a lower predicted mortality ratio than those who did not (0.07 vs 0.23, p < 0.001). The primary limitations of our study included its retrospective nature and the use of predicted mortalities.
At reclassification, nearly half of patients had a more than five-fold and one in five patients had a more than ten-fold higher risk of non-PCa death than patients having a risk of untreated PCa death. Despite a more significant cancer diagnosis, a transition to WW for older men with multiple comorbidities and grade group <3 PCa should be considered.
Men with favorable-risk prostate cancer and life expectancy of >10 yr are often enrolled in active surveillance, which entails delay of curative treatment until there is evidence of more aggressive disease. We examined a group of men on active surveillance who developed more aggressive disease, and found, nevertheless, that the majority of these men continued to have a dramatically higher risk of death from non-prostate cancer causes than from prostate cancer based on a risk prediction tool. For men older than 75 yr, who have multiple medical conditions and who do not have higher-grade cancer, it may be reasonable to reconsider the need for curative treatment given the low risk of death from prostate cancer compared with the risk of death from other causes.
对于接受前列腺癌（PCa）主动监测（AS）的男性，疾病进展和与年龄相关的健康变化可能会影响他们对接受根治性治疗的决策。
评估 AS 男性重新分类时 PCa 和非 PCa 死亡率的预测值，确定从 AS 过渡到观察等待（WW）的临床标准。
设计、地点和参与者：回顾性检查了在大型 AS 项目中经历活检分级重新分类（Gleason 分级增加）的患者。所有在重新分类时完整记录了合并症的患者均被纳入研究。
使用验证过的模型，根据患者合并症和 PCa 临床特征，评估未经治疗的 10 年和 15 年 PCa 和非 PCa 死亡率。我们比较了预测 PCa 死亡率与预测非 PCa 死亡率的比值（“预测死亡率比值”），并根据该比值将患者分为四个风险等级：（1）等级 1（比值>0.33），（2）等级 2（比值 0.33-0.20），（3）等级 3（比值 0.20-0.10），和（4）等级 4（比值<0.10）。
在 344 名重新分类的患者中，98 名（28%）处于 10 年死亡率风险等级 1，85 名（25%）处于等级 2，93 名（27%）处于等级 3，68 名（20%）处于等级 4。15 年风险等级分布相似。23 名（6.7%）符合“过渡三联征”（年龄>75 岁、Charlson 合并症指数>3、分级组≤2）的患者，非 PCa 死亡率风险高 14 倍，预测死亡率比值低（0.07 比 0.23，p<0.001）。本研究的主要局限性包括其回顾性性质和使用预测死亡率。
在重新分类时，近一半的患者死于非 PCa 的风险是死于未经治疗的 PCa 的风险的五倍以上，五分之一的患者死于非 PCa 的风险是死于未经治疗的 PCa 的风险的十倍以上。尽管癌症诊断更严重，但对于合并多种疾病且分级组<3 的老年男性，应考虑从 WW 过渡。
预期寿命超过 10 年的低危前列腺癌男性通常会接受主动监测，这需要延迟根治性治疗，直到有更具侵袭性疾病的证据。我们检查了一组接受主动监测且疾病进展为侵袭性的男性，发现，尽管如此，根据风险预测工具，这些男性中仍有大多数死于非前列腺癌原因的风险显著高于死于前列腺癌的风险。对于年龄>75 岁、有多种合并症且没有高级别癌症的男性，考虑到与其他原因导致的死亡风险相比，死于前列腺癌的风险较低，可能有必要重新考虑是否需要根治性治疗。
