Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, 1133 York Avenue, New York, NY, 10065, USA.
Department of Urology, Uppsala University, Uppsala, Sweden.
BMC Urol. 2023 Sep 30;23(1):152. doi: 10.1186/s12894-023-01314-6.
Treatment decisions for localized prostate cancer must balance patient preferences, oncologic risk, and preservation of sexual, urinary and bowel function. While Active Surveillance (AS) is the recommended option for men with Grade Group 1 (Gleason Score 3 + 3 = 6) prostate cancer without other intermediate-risk features, men with Grade Group 2 (Gleason Score 3 + 4 = 7) are typically recommended active treatment. For select patients, AS can be a possible initial management strategy for men with Grade Group 2. Herein, we review current urology guidelines and the urologic literature regarding recommendations and evidence for AS for this patient group.
AS benefits men with prostate cancer by maintaining their current quality of life and avoiding treatment side effects. AS protocols with close follow up always allow for an option to change course and pursue curative treatment. All the major guideline organizations now include Grade Group 2 disease with slightly differing definitions of eligibility based on risk using prostate-specific antigen (PSA) level, Gleason score, clinical stage, and other factors. Selected men with Grade Group 2 on AS have similar rates of deferred treatment and metastasis to men with Grade Group 1 on AS. There is a growing body of evidence from randomized controlled trials, large observational (prospective and retrospective) cohorts that confirm the oncologic safety of AS for these men. While some men will inevitably conclude AS at some point due to clinical reclassification with biopsy or imaging, some men may be able to stay on AS until transition to watchful waiting (WW). Magnetic resonance imaging is an important tool to confirm AS eligibility, to monitor progression and guide prostate biopsy.
AS is a viable initial management option for well-informed and select men with Grade Group 2 prostate cancer, low volume of pattern 4, and no other adverse clinicopathologic findings following a well-defined monitoring protocol. In the modern era of AS, urologists have tools at their disposal to better stage patients at initial diagnosis, risk stratify patients, and gain information on the biologic potential of a patient's prostate cancer.
局限性前列腺癌的治疗决策必须平衡患者的偏好、肿瘤风险以及对性功能、尿控和排便功能的保护。虽然主动监测（AS）是无其他中危特征的 Gleason 评分 3+3=6 级组 1（Gleason 分级 1 组）前列腺癌患者的推荐选择，但 Gleason 评分 3+4=7 级组 2（Gleason 分级 2 组）的男性通常建议积极治疗。对于某些患者，AS 可能是一种可行的初始管理策略，适用于 Gleason 分级 2 组的男性患者。在此，我们回顾了当前的泌尿科指南和泌尿科文献中关于该患者群体 AS 的建议和证据。
AS 通过维持患者当前的生活质量并避免治疗的副作用使前列腺癌患者受益。密切随访的 AS 方案始终允许改变治疗方案并选择根治性治疗。现在所有主要的指南组织都将 Gleason 分级 2 疾病纳入其中，根据前列腺特异性抗原（PSA）水平、Gleason 评分、临床分期和其他因素，对其纳入标准有略有不同的定义。在 AS 治疗的 Gleason 分级 2 患者中，有相似比例的患者延迟治疗并发生转移，与 AS 治疗的 Gleason 分级 1 患者相似。越来越多的随机对照试验和大型观察性（前瞻性和回顾性）队列研究的证据证实了 AS 对这些患者的肿瘤安全性。虽然一些患者最终会因活检或影像学检查的临床再分类而在某个时间点终止 AS，但一些患者可能能够继续 AS 治疗，直到过渡到观察等待（WW）。磁共振成像（MRI）是确认 AS 适应证、监测进展和指导前列腺活检的重要工具。
对于信息充分且选择合适的 Gleason 分级 2 前列腺癌患者、低体积模式 4 且无其他不良临床病理特征的患者，遵循明确的监测方案，AS 是一种可行的初始治疗选择。在 AS 的现代时代，泌尿科医生拥有更好地对初始诊断患者进行分期、对患者进行风险分层以及获取患者前列腺癌生物学潜力信息的工具。
