Department of Urology, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
Department of Urology, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
Urol Oncol. 2023 Feb;41(2):82-87. doi: 10.1016/j.urolonc.2021.08.008. Epub 2021 Sep 3.
Currently available data from long-running single- and multi-center active surveillance (AS) studies show that AS has excellent cancer-specific survival rates. For AS to be effective the 'right' patients should be selected for which up until 5-to-10 years ago systematic prostate biopsies were used. Because the systematic prostate strategy relies on sampling efficiency for the detection of prostate cancer (PCa), it is subject to sampling error. Due to this sampling error, many of the Gleason 3+3 PCas that were included on AS in the early days and were classified as low-risk, may in fact have had a higher Gleason score. Subsequently, AS-criteria were more strict to overcome or limit the number of men missing the potential window of curability in case their tumor would be reclassified. Five to ten years ago the prostate biopsy landscape changed drastically by the addition of magnetic resonance imaging (MRI) into the diagnostic PCa-care pathway, which has by now trickled down into the EAU guidelines. At the moment, the EAU guidelines recommend performing a (multi-parametric) MRI before prostate biopsy and combine systematic and targeted prostate biopsy when the MRI is positive (i.e. PIRADS ≥3). So because of the introduction of the MRI into the diagnostic PCa-care pathway, literature is showing that more Gleason 3+4 PCas are being diagnosed. But can it not be that the inclusion of MRI into the diagnostic PCa-care pathway causes risk inflation, resulting in men earlier eligible for AS, now being labelled ineligible for AS? Would it not be possible to include these current Gleason 3+4 PCas on AS? The authors hypothesize that the improved accuracy that comes with the introduction of MRI into the diagnostic PCa-care pathway permits to widen both the AS-inclusion and follow-up criteria. Maintaining our inclusion criteria for AS from the systematic biopsy era will unnecessarily and undesirably expose patients to the increased risk of overtreatment. The evidence behind the addition of MRI-targeted biopsies to systematic biopsies calls upon the re-evaluation of the AS inclusion criteria and research from one-size-fits-all protocols used so far, into the direction of more dynamic and individual risk-based AS-approaches.
目前，来自长期单中心和多中心主动监测（AS）研究的现有数据表明，AS 具有出色的癌症特异性生存率。为了使 AS 有效，应该选择“合适”的患者，直到 5 到 10 年前，系统的前列腺活检一直被用于此。由于系统的前列腺策略依赖于前列腺癌（PCa）检测的采样效率，因此存在采样误差。由于这种采样误差，许多在早期被纳入 AS 的 Gleason 3+3 PCa 被归类为低危，实际上可能具有更高的 Gleason 评分。随后，为了克服或限制因肿瘤重新分类而错过潜在可治愈期的男性数量，AS 标准更加严格。大约 5 到 10 年前，前列腺活检领域发生了巨大变化，磁共振成像（MRI）被纳入诊断性 PCa 治疗途径，现在已经被纳入 EAU 指南。目前，EAU 指南建议在前列腺活检前进行（多参数）MRI，并在 MRI 阳性时（即 PIRADS≥3）结合系统和靶向前列腺活检。因此，由于 MRI 被纳入诊断性 PCa 治疗途径，文献显示更多的 Gleason 3+4 PCa 被诊断出来。但是，是否有可能不是因为 MRI 被纳入诊断性 PCa 治疗途径导致风险膨胀，从而使更早有资格接受 AS 的男性现在被标记为不适合 AS？是否有可能将这些当前的 Gleason 3+4 PCa 纳入 AS？作者假设，MRI 被引入诊断性 PCa 治疗途径所带来的准确性提高，允许放宽 AS 纳入和随访标准。从系统活检时代保留我们的 AS 纳入标准将不必要且不希望地使患者面临过度治疗的风险增加。将 MRI 靶向活检添加到系统活检背后的证据呼吁重新评估 AS 纳入标准，并研究迄今为止使用的一刀切协议，朝着更具动态性和个体化的基于风险的 AS 方法方向发展。
