title: Active surveillance in patients with a PSA >10 ng/mL.
abstract: BACKGROUND
  The use of prostate-specific antigen (PSA) in active surveillance (AS) for prostate cancer is controversial. Some consider it an unreliable marker and others as sufficient evidence to exclude patients from AS. We analyzed our cohort of AS patients with a PSA over 10 ng/mL.
  
  
  METHODS
  We included patients who had clinical T1c-T2a Gleason ≤6 disease, and ≤3 positive cores with ≤50% core involvement at diagnostic biopsy and ≥2 total biopsies. Patients were divided into 3 groups: (1) those with baseline PSA >10 ng/mL, (2) those with a PSA rise >10 ng/mL during follow-up; and (3) those with a PSA <10 ng/mL throughout AS. Adverse histology was defined as biopsy parameters exceeding the entry criteria limits. We further compared this cohort to a concurrent institutional cohort with equal biopsy parameters treated with immediate radical prostatectomy.
  
  
  RESULTS
  Our cohort included 698 patients with a median follow-up of 46.2 months. In total, 82 patients had a baseline PSA >10 ng/mL and 157 had a PSA rise >10 ng/mL during surveillance. No difference in adverse histology incidence was detected between groups (p = 0.3). Patients with a PSA greater than 10 were older and had higher prostate volumes. Hazard ratios for groups with a PSA >10 were protective against adverse histology. Larger prostate volume and minimal core involvement appear as factors related to this successful selection of patients to be treated with AS.
  
  
  CONCLUSIONS
  These results suggest that a strict cut-off PSA value for all AS patients is unwarranted and may result in overtreatment. Though lacking long-term data and validation, AS appears safe in select patients with a PSA >10 ng/mL and low volume Gleason 6 disease.
authors.affiliation: Department of Urologic Sciences, University of British Columbia, Vancouver, BC;
authors.forename: Paul
authors.initials: P
authors.lastname: Toren
authors.affiliation: Department of Urology, St. Vincent's Hospital and Austin Health, University of Melbourne, Victoria, Australia;
authors.forename: Lih-Ming
authors.initials: LM
authors.lastname: Wong
authors.affiliation: Department of Surgery (Urology), University of Toronto, Princess Margaret Hospital, Toronto, ON;
authors.forename: Narhari
authors.initials: N
authors.lastname: Timilshina
authors.affiliation: Department of Medicine and Institute of Health Policy, Management, and Evaluation, University Health Network and University of Toronto, Toronto, ON.
authors.forename: Shabbir
authors.initials: S
authors.lastname: Alibhai
authors.affiliation: Department of Surgery (Urology), University of Toronto, Princess Margaret Hospital, Toronto, ON;
authors.forename: John
authors.initials: J
authors.lastname: Trachtenberg
authors.affiliation: Department of Surgery (Urology), University of Toronto, Princess Margaret Hospital, Toronto, ON;
authors.forename: Neil
authors.initials: N
authors.lastname: Fleshner
authors.affiliation: Department of Surgery (Urology), University of Toronto, Princess Margaret Hospital, Toronto, ON;
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli