Active surveillance failure for prostate cancer:  does the delay in treatment increase the risk of urinary incontinence?
BACKGROUND
Active surveillance for low risk prostate cancer has become an acceptable management strategy.  However, a percentage of these patients in active surveillance move on to active treatment.  Our aim was to examine urinary incontinence (UI) rates in men who move on to treatment from active surveillance and compare it to quoted rates in the literature.  We examined the question that a potential delay in the treatment of prostate cancer in those on active surveillance may result in an increase in incontinence rates.


METHODS
From July 1992 to June 2009, 443 men at our institution entered into active surveillance for newly diagnosed prostate cancer.  We reviewed their medical records and data was abstracted from physician-reported medical records.  The mean age of the entire group was 64.1 years old (range 40-80).  Their mean prostate-specific antigen (PSA) was 7.65 (range 0.21-36) and their mean Gleason score was 6.2 (range 4-8).  Of these patients on active surveillance, 150/443 (33.3%) went on to active treatment.  Median time to active treatment was 31.5 months (range 3-180 months).  Only 5 patients went onto active treatment less than 1 year after starting active surveillance.  Of these patients who went onto active treatment, 85 had radiation alone, 48 had a radical prostatectomy (RP), 7 had a RP and radiation, 7 had HIFU alone, 2 had focal ablation and 1 had HIFU followed by salvage RP.  Of those undergoing radiation (92 patients), 66 had external beam and 26 had brachytherapy.


RESULTS
Prior to active treatment 25/443 (5.6%) patients had UI documented in their history.  Of those 25 patients only 3 went on to a RP and all had persistent UI after surgery. Two of the 25 patients went on to radiation therapy and their UI resolved.  In the active treatment groups, after RP alone, 14/48 (29.2%) patients had new onset UI that persisted at a mean of 47.2 months (range 11-149 months) postoperatively.  Of these 14 patients, 7 patients (14.6%) had significant leakage (> 1 pad/day).  After radiation therapy alone 2/85(2.4%) had new onset persistent UI at 34 and 49 months post radiation.  Only 1/7 (14.3%) patients that had high intensity focused ultrasound (HIFU) alone had persistent UI at 38 months after HIFU.  Of the 7 patients that had both a RP and radiation, 2 had persistent significant UI at 49 and 153 months after surgery.  One patient that had HIFU and a RP had persistent UI at 23 months post surgery.  The 2 patients that had focal ablation were dry.


CONCLUSIONS
The UI rates in our cohort of active surveillance patients who move on to active treatment are similar to patients who undergo treatment immediately after prostate cancer is diagnosed as quoted in the literature.  This suggests that active surveillance, as an initial mode of therapy, does not increase the risk of UI if active treatment occurs at a later date.
Division of Urology, Princess Margaret Hospital, Toronto, Ontario, Canada.
Lenny
L
Radomski
Johan
J
Gani
Greg
G
Trottier
Antonio
A
Finelli
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D011159:Population Surveillance; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000150:complications* / Q000473:pathology* / Q000628:therapy; D013997:Time Factors; D036761:Ultrasound, High-Intensity Focused, Transrectal; D014549:Urinary Incontinence / Q000209:etiology*
D017430:Prostate-Specific Antigen