Expanded criteria for active surveillance in prostate cancer: a review of the current data

Over the last ten years, active surveillance (AS) has become increasingly utilized for patients with low-risk prostate cancer. Appropriately selected AS patients have a 10-year prostate cancer-specific mortality (PCSM) approaching 99%. Therefore, some institutions have expanded the inclusion criteria for AS to avoid the unnecessary morbidity associated with overtreatment. In this review, data from several high-quality studies were compiled to demonstrate how AS inclusion criteria may be safely expanded. Although AS criteria, data reporting, and statistical methods were heterogeneous across studies, several findings were consistent and provided insight for clinical practice. Gleason score >= 3+4 and prostate specific antigen density (PSAd) >= 0.15 ng/mL were consistently associated poor oncologic outcomes [biopsy reclassification/progression, adverse pathology at prostatectomy, biochemical recurrence (BCR), and PCSM]. Maximum single-core involvement, number of positive cores, and clinical stage were not consistently associated with negative outcomes. These data support the safety of expanded AS inclusion criteria beyond Epstein's very low-risk (VLR) criteria to include patients with clinical stage T2, up to 60% maximum core involvement, and up to 4 positive cores (Gleason 3+3 and <= PSAd 0.15 ng/mL). Furthermore, although it is clear that patients with intermediate-risk disease have poorer oncologic outcomes compared to low-risk, the absolute 10-year PCSM remains low and select patients may be optimally managed with AS. Although AS utilization is increasing, many men who might be safely managed with AS are still undergoing morbid and unnecessary definitive treatments. Further research into clinical parameters such as multiparametric magnetic resonance imaging (mpMRI) and genetic testing is required to improve the accuracy of patient stratification.