Oncology Impact of Race on Selecting Appropriate Patients for Active Surveillance With Seemingly Low-risk Prostate Cancer Eugene J. Pietzak, Keith Van Arsdalen, Kinnari Patel, S. Bruce Malkowicz, Alan J. Wein, and Thomas J. Guzzo OBJECTIVE METHODS
RESULTS
CONCLUSION
To evaluate active surveillance (AS) criteria on their ability to predict favorable pathology at prostatectomy within a low-risk African American (AA) cohort. The sensitivity, specificity, positive predictive value, receiver operator curve, and area under the curve (AUC) were compared for 6 published AS criteria (National Comprehensive Cancer Network; Memorial Sloan-Kettering Cancer Center; Prostate Cancer Research International: Active Surveillance Study; Johns HopkinseEpstein; University of California at San Francisco; and University of Miami) to predict organ-confined Gleason score 6 disease at prostatectomy in AAs and white Americans (WAs) with low-risk cancer. We also compared clinical parameters for AAs with favorable prostatectomy pathology with those for AAs with unfavorable pathology, and then used preoperative variables associated with unfavorable pathology as an additional exclusion criteria for AS. Of 468 patients with low-risk disease, 308 of 402 (76.6%) WAs and 55 of 66 (83.3%) AAs were eligible for AS by one or more criteria (P ¼ .23). For WAs, Prostate Cancer Research International: Active Surveillance Study criteria had the highest rate of favorable pathology (81.7%) and the best performance (AUC ¼ 0.70) in determining appropriate candidates for AS. However, all 6 AS criteria performed poorly for AA patients, with all AUCs 0.52. When comparing AAs with favorable pathology with AAs with unfavorable pathology, only family history of prostate cancer was statistically significant (11 of 25 [47.8%] vs 8 of 41 [22.2%]; P ¼ .04). When adjusting AS criteria in AAs to exclude those with a positive family history, the AUC increased most for the University of California at San Francisco (from 0.52 to 0.6) and Memorial SloanKettering Cancer Center criteria (from 0.50 to 0.58). Current criteria underperform in appropriately selecting AAs for AS. AAs considering AS should be counseled about their increased risk for occult adverse pathology, particularly if a family history of prostate cancer is present. UROLOGY 85: 436e441, 2015. 2015 Elsevier Inc.
A
ctive surveillance (AS) as the initial management strategy for low-risk prostate cancer (PCa) has increased in recent years. This is largely driven by the recognition of the adverse effects associated with treatment for patients unlikely to experience mortality or metastasis from their low-risk disease.1 Despite the growing popularity of AS for low-risk patients, increasing evidence has emerged questioning the safety of this approach in minority populations, particularly Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: This research was supported by the Linda and Joel Appel Prostate Cancer Research Fund. Division of Urology, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, PA Address correspondence to: Eugene J. Pietzak M.D., Division of Urology, Department of Surgery, Hospital of University of Pennsylvania, 3 West Pavilion, Perelman Center for Advanced Medicine, Philadelphia, PA 19104. E-mail: Eugene.pietzak@ uphs.upenn.edu Submitted: May 23, 2014, accepted (with revisions): September 19, 2014
436
ª 2015 Elsevier Inc. All Rights Reserved
African Americans (AAs).2 Several retrospective studies have found that AAs eligible for AS, but who instead underwent immediate radical prostatectomy (RP), are more likely to have occult adverse pathology compared with white Americans (WAs).2,3 Furthermore, AAs who are initially managed with AS are more likely to have disease progression while on AS, compared with WAs.4-6 The disparity between AAs and WAs who are eligible for AS suggests that current AS selection criteria may be inappropriate for AAs. This is not overly surprising because most of the published AS series cohorts are composed of
RESULTS
CONCLUSION
To evaluate active surveillance (AS) criteria on their ability to predict favorable pathology at prostatectomy within a low-risk African American (AA) cohort. The sensitivity, specificity, positive predictive value, receiver operator curve, and area under the curve (AUC) were compared for 6 published AS criteria (National Comprehensive Cancer Network; Memorial Sloan-Kettering Cancer Center; Prostate Cancer Research International: Active Surveillance Study; Johns HopkinseEpstein; University of California at San Francisco; and University of Miami) to predict organ-confined Gleason score 6 disease at prostatectomy in AAs and white Americans (WAs) with low-risk cancer. We also compared clinical parameters for AAs with favorable prostatectomy pathology with those for AAs with unfavorable pathology, and then used preoperative variables associated with unfavorable pathology as an additional exclusion criteria for AS. Of 468 patients with low-risk disease, 308 of 402 (76.6%) WAs and 55 of 66 (83.3%) AAs were eligible for AS by one or more criteria (P ¼ .23). For WAs, Prostate Cancer Research International: Active Surveillance Study criteria had the highest rate of favorable pathology (81.7%) and the best performance (AUC ¼ 0.70) in determining appropriate candidates for AS. However, all 6 AS criteria performed poorly for AA patients, with all AUCs 0.52. When comparing AAs with favorable pathology with AAs with unfavorable pathology, only family history of prostate cancer was statistically significant (11 of 25 [47.8%] vs 8 of 41 [22.2%]; P ¼ .04). When adjusting AS criteria in AAs to exclude those with a positive family history, the AUC increased most for the University of California at San Francisco (from 0.52 to 0.6) and Memorial SloanKettering Cancer Center criteria (from 0.50 to 0.58). Current criteria underperform in appropriately selecting AAs for AS. AAs considering AS should be counseled about their increased risk for occult adverse pathology, particularly if a family history of prostate cancer is present. UROLOGY 85: 436e441, 2015. 2015 Elsevier Inc.
A
ctive surveillance (AS) as the initial management strategy for low-risk prostate cancer (PCa) has increased in recent years. This is largely driven by the recognition of the adverse effects associated with treatment for patients unlikely to experience mortality or metastasis from their low-risk disease.1 Despite the growing popularity of AS for low-risk patients, increasing evidence has emerged questioning the safety of this approach in minority populations, particularly Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: This research was supported by the Linda and Joel Appel Prostate Cancer Research Fund. Division of Urology, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, PA Address correspondence to: Eugene J. Pietzak M.D., Division of Urology, Department of Surgery, Hospital of University of Pennsylvania, 3 West Pavilion, Perelman Center for Advanced Medicine, Philadelphia, PA 19104. E-mail: Eugene.pietzak@ uphs.upenn.edu Submitted: May 23, 2014, accepted (with revisions): September 19, 2014
436
ª 2015 Elsevier Inc. All Rights Reserved
African Americans (AAs).2 Several retrospective studies have found that AAs eligible for AS, but who instead underwent immediate radical prostatectomy (RP), are more likely to have occult adverse pathology compared with white Americans (WAs).2,3 Furthermore, AAs who are initially managed with AS are more likely to have disease progression while on AS, compared with WAs.4-6 The disparity between AAs and WAs who are eligible for AS suggests that current AS selection criteria may be inappropriate for AAs. This is not overly surprising because most of the published AS series cohorts are composed of
![[Active surveillance for prostate cancer].](/assets/img/hold.png)
