Novel tools to improve patient selection and monitoring on active surveillance for low-risk prostate cancer: a systematic review.
BACKGROUND
Active surveillance (AS) is an alternative to initial radical treatment of low-risk prostate cancer (PCa). Current criteria for selection and follow-up incorrectly exclude some patients eligible for AS and misclassify some who actually harbour significant disease. Better prediction of cancer behaviour at diagnosis would allow less strict monitoring and may improve acceptance of AS.


OBJECTIVE
To review and critically analyse the literature on the value of novel clinical tools for patient selection and monitoring on AS.


METHODS
A comprehensive search of the PubMed database until July 10, 2013, was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. Studies assessing novel markers and diagnostics for patient selection for AS and follow-up during AS were included. Studies analysing only classic clinical parameters used in current protocols (prostate-specific antigen, prostate volume, number of (positive) prostate biopsies, percentage malignant tissue, Gleason score) were excluded. This review focuses only on the AS setting and not on predicting insignificant disease in general.


RESULTS
Of 787 studies on AS, 30 were included in this review: 14 on magnetic resonance imaging (MRI), 5 on serum markers, 5 on urinary markers, 4 on histopathology markers, and 2 on germline genetic markers. Several of these markers improve the prediction of tumour volume, tumour grade, or time to active treatment. MRI has a high specificity for low-risk PCa; new serum markers are associated with unfavourable disease. In none of the studies was the new marker used as the primary decision tool. Long-term outcome measures such as mortality were not assessed. The definition of indolent PCa is disputable.


CONCLUSIONS
Imaging and serum markers may improve future patient selection for AS and follow-up during AS. Prospective studies should aim to further evaluate the clinical utility of these new markers with respect to longer term outcomes of AS.


RESULTS
We searched the literature for articles reporting new ways to safely monitor low-risk prostate cancer for patients who have not had radical treatment. We found 30 articles. The most promising tools appear to be magnetic resonance imaging scans and various new blood markers. These may be used in the future within active surveillance regimens.
University Medical Centre, Utrecht, The Netherlands. Electronic address: roodvdb@hotmail.com.
Roderick C N
RC
van den Bergh
University College London, London, UK.
Hashim U
HU
Ahmed
Erasmus University Medical Centre, Rotterdam, The Netherlands.
Chris H
CH
Bangma
Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.
Matthew R
MR
Cooperberg
CHRU Lille, Université Lille Nord de France, Lille, France.
Arnauld
A
Villers
Royal Marsden Hospital, Sutton, UK.
Christopher C
CC
Parker
D000951:Antigens, Neoplasm / Q000652:urine; D014408:Biomarkers, Tumor / Q000097:blood* / Q000652:urine; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D018579:Patient Selection; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000097:blood* / Q000235:genetics / Q000473:pathology / Q000628:therapy* / Q000652:urine; D012307:Risk Factors; D057832:Watchful Waiting
D000951:Antigens, Neoplasm; D014408:Biomarkers, Tumor; C479341:prostate cancer antigen 3, human; D017430:Prostate-Specific Antigen
Active surveillance; Expectant management; Histopathology; MRI; Markers; PSA; Prostate cancer; Urinary