Introduction

Active surveillance (AS) is increasingly used in managing low-risk prostate cancer. Data on outcomes of AS in younger men are limited. We present characteristics and outcomes of two cohorts of men who began AS at under 60 years of age.

Methods

We reviewed our institutional AS databases at the Massachusetts General Hospital (MGH) (n = 990) and Sunnybrook Health Sciences Centre (n =1162) of men diagnosed with low-risk prostate cancer between 1990-2016 to identify 432 men under age 60 (n = 181, MGH; n = 251, Sunnybrook). Clinical outcomes were analyzed, including repeat biopsy data, progression to treatment, and pathologic staging in those who had surgical treatment. Survival estimates were generated by Kaplan-Meier analysis.

Results

At diagnosis, median age was 55 years (IQR 53-57) and median PSA was 4.6 ng/mL (IQR 3.1-5.9), with only 11 of 432 men with PSA ≥10 ng/mL. The vast majority of patients had Gleason ≤6 (97.7%) and clinical stage T1 (91.9%) disease. With a median follow-up of 5.1 years (range: 0.05-21.7; IQR: 3.1-8.4), 84.3% (364/432) had a repeat biopsy with 62.6% (228/364) showing prostate cancer, 24.5% (89/364) benign, 7.7% (28/364) with PIN, and 5.2% (10/364) with atypia. Kaplan-Meier actuarial freedom-from-treatment was 74.3% at 5 years and 55.4% at 10 years. Of all 432 patients, 131 (30.3%) progressed to treatment for the following reasons: pathologic progression (64.1%), PSA progression (18.3%), patient preference (11.5%), volume progression (3.1%) and other reasons (3.1%). Among the 131 treated patients, 62.6% underwent radical prostatectomy, 13.0% underwent high-intensity focal ultrasound therapy, 12.2% underwent external beam radiation and 10.7% had brachytherapy. On pathologic review after surgery, 88.2% (60/68) were pT2, and 11.8% (8/68) pT3. Five patients developed metastasis (2 with positive lymph nodes at time of radical prostatectomy, 3 with distant metastasis). Metastasis-free survival was 99.7% and 97.5% at 5 and 10 years, respectively. There were no prostate-cancer specific deaths.

Conclusions

Active surveillance is a reasonable option for carefully selected men under 60 with low-risk prostate cancer. However, patients must be surveyed closely and understand the significant risk of ultimately needing treatment.

Funding

None