EURURO Vol. 71 No. 5

833 844

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
expectancy [1].
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 [2]. The establish-
ment of appropriate patient classification criteria is ongoing
[3,4]. 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 [1,2,5]. 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 [2]. 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.
References
[1]
.
[2]
.
[3]
[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 (p = 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% ( p = 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; p < 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 p < 0.007).
Experts’ comments:
On the basis of current scientific and health economy discus-
sions around prostate-specific antigen (PSA) screening and
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