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Top Line: What’s the main difference in prostate cancer outcomes for active surveillance compared to up-front treatment?

The Study: It’s the small but real risk of disease progression or metastasis during surveillance of what was presumed to be low-risk disease. Part of that risk comes from the incomplete information we rely on to stratify patients. So, where are we with using genomics to risk stratify men undergoing active surveillance? Oncotype has a 17-gene Genomic Prostate Score (GPS) that is a good predictor of adverse pathology on prostatectomy. Knowing who has such adverse pathology (grade group 3+ or pT3+ disease) would increase the confidence and perhaps the safety of active surveillance. The Canary Prostate Active Surveillance Study (PASS) is a prospective active surveillance study for men with localized prostate cancer that looks at the ability of GPS to predict adverse pathology. Protocol surveillance was fairly intensive and any form of biochemical, grade, or clinical progression could prompt treatment. Over 400 men had the GPS performed on initial biopsy, and just over 100 eventually had a prostatectomy. Half of these had adverse pathology (which is a fairly small number when talking about prostate cancer). The only individual factor that alone was associated with adverse path was PSA density. GPS wasn’t independently associated with adverse path. It also wasn’t associated with path upgrading on subsequent biopsy. However, adding GPS results to grade group and PSA density did increase the proportion of men categorized at “high risk” of adverse path.

TBL: Oncotype doesn’t appear to be the silver bullet for identifying which men should feel most comfortable with active surveillance for prostate cancer. | Lin, J Clin Oncol 2020