Surveillance at the Margins: Management of High-Volume Gleason 6, PSA > 10, or Gleason 3 + 4

Abstract

Purpose of review: Active surveillance is now widely utilized for the management of low-risk prostate cancer (PCa). The limit of surveillance for men with intermediate-risk cancer is controversial. While there is a broad consensus that men with low-risk disease can be safely managed with AS, many potential candidates, including those with Gleason 3 + 4 disease, PSA > 10, younger men and African-Americans are often excluded.

Recent findings: Outcome data for intermediate-risk patients managed by active surveillance demonstrate reasonable outcomes, but these men clearly are at higher risk for progression to metastatic disease. The use of biomarkers and multiparametric MRI will enable a more precise and personalized risk assessment. Literature describing the effects of young age on outcomes is limited, but the experience reported in prospective series with 15–20 year follow-up suggests it is a safe approach. African-American men are at greater risk for occult coexistent higher-grade disease, but in the absence of this, their outcome is favorable.

Summary: Patients with intermediate-risk PCa should not be excluded from active surveillance based on one criterion. Treatment decisions should be based on multiple parameters, including percent Gleason 4, PSA density, cancer volume on biopsy, MRI findings, and patient age and comorbidity. Genetic tissue-based biomarkers are also likely to play a role in enhancing decision-making.