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Re: Long-term Results of Active Surveillance in the

Go¨ teborg Randomized, Population-based Prostate

Cancer Screening Trial

Godtman RA, Holmberg E, Khatami A, Pihl CG, Stranne J,

Hugosson J

Eur Urol 2016;70:760–6

Experts’ summary:

The study evaluated the long-term safety of active surveil-

lance (AS) for men with screen-detected prostate cancer (PCa)

and extended over a period of 15 yr. A total of 474 patients

were primarily managed with AS. The median follow-up was

8.0 yr (range 0.1–18.3). Some 202 men underwent treatment

during the follow-up period. The 10-yr and 15-yr treatment-

free survival was 47% and 34%, respectively. In comparison to

patients with very low-risk PCa, those with low- and inter-

mediate-risk PCa were at 1.4 and 1.6 times higher risk of

treatment and 2.2 and 4.8 times higher risk of AS failure,

respectively. Six patients died from PCa, none of whom were

in the very low-risk group. The 10-yr and 15-yr PCa-specific

survival was 99.5% and 96%, respectively. The authors con-

cluded that some patients will miss their chance of cure while

on AS, and the approach may not be suitable for patients not

fulfilling the criteria for very low risk or patients with long life




Experts’ comments:

The study showed that AS may compromise any cure for

patients not classified in the very low risk group. The concept

of AS has matured during the last decade, and the urology

community seems to have embraced AS for the management

of selected patients. Nevertheless, current evidence requires

careful interpretation owing to the significant variation among

AS studies in terms of patient selection, follow-up protocols,

and the criteria for initiation of treatment


. The establish-

ment of appropriate patient classification criteria is ongoing


. The introduction of appropriate follow-up strategies,

including modern diagnostic modalities, requires significant

clinical evaluation, and the evidence will be available after a

considerable time period


. Thus, AS should be proposed

after a very careful diagnostic and clinical evaluation.

According to the study, AS should probably be proposed

only for patients who could be classified as very low risk

and do not have very long life expectancy. These are the only

patients who would not miss their chance for cure and, more

importantly, are not at risk of dying from PCa. These sugges-

tions are further documented by the presence of pT3 stage

tumors in 17–44% of the prostatectomy specimens from

patients initially managed by AS


. Considering the above,

our practice should carefully integrate AS with the majority

of our patients being treated with one of the well-documen-

ted modalities.

Conflicts of interest:

The authors have nothing to disclose.



Godtman RA, Holmberg E, Khatami A, Pihl CG, Stranne J, Hugosson J. Long-term results of active surveillance in the Go¨teborg random- ized, population-based prostate cancer screening trial. Eur Urol 2016;70:760–6



Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol 2017;71:618–29



Gettman MT. Thoughts on criteria for active surveillance of favor- able-risk prostate cancer. Eur Urol 2016;70:961–2.

[4] Herden J, Heidenreich A, Weissbach L. Risk stratification: a tool to

predict the course of active surveillance for localized prostate

cancer? BJU Int. In press. .

[5] Oberlin DT, Casalino DD, Miller FH, Meeks JJ. Dramatic increase in

the utilization of multiparametric magnetic resonance imaging for

detection and management of prostate cancer. Abdom Radiol. In

press. .

Panagiotis Kallidonis, Evangelos Liatsikos


Department of Urology, University of Patras, Patras, Greece

*Corresponding author. Department of Urology, University of Patras,

Patras 26504, Greece.

E-mail address:

(E. Liatsikos).


2017 European Association of Urology.

Published by Elsevier B.V. All rights reserved.

Re: The Role of Adjuvant Radiotherapy in Pathologically

Lymph Node Positive Prostate Cancer

Jegadeesh N, Liu Y, Zhang C, et al.

Cancer 2017;123:512–20

Experts’ summary:

Jegadeesh et al examined overall survival (OS) outcomes using

data retrieved from the National Cancer Database for

2569 patients diagnosed with lymph node–positive (any pT

pN1M0) prostate adenocarcinoma (PCa) and treated with

radical prostatectomy (RP) between 2003 and 2011. A total

of 906 patients (35.3%) received postoperative adjuvant ra-

diotherapy (ART) combined with androgen deprivation ther-

apy (ADT), resulting in a 5-yr OS rate of 87%, compared to 82%

for patients who received ADT alone (


= 0.007). Extended

Kaplan-Meier curves indicated 10-yr OS of approximately

70% for patients receiving ADT together with radiotherapy.

The improvement in OS was maintained after propensity score

matching, with 5-yr OS of 88% versus 81% (


= 0.004) favoring

combined treatment (hazard ratio [HR] 1.43, 95% confidence

interval [CI] 1.10–1.86). On multivariable Cox proportional-

hazards analysis, the benefit achieved by ART remained, with

a HR of 1.50 (95% CI 1.18–1.90;



0.001) compared to

patients not receiving ART. Further factors independently

associated with poorer OS were, among others, the presence

of more than two lymph nodes involved, positive surgical

margins, pathological tumor stage 3–4, and Gleason score

8–10 (each




Experts’ comments:

On the basis of current scientific and health economy discus-

sions around prostate-specific antigen (PSA) screening and

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 8 3 1 – 8 3 6