Aug 2026· Tumori· pp.
3008916261468121
· 0 citations· 31 references
Medicine
TL;DR
A model using simple, routine parameters and PSA doubling time can identify those at minimal risk of reclassification, enabling a safe reduction in biopsy intensity, and advocates for a risk-adaptive AS protocol.
Abstract
Background
Active surveillance (AS) is standard for early-stage prostate cancer, though intensive monitoring continues due to concerns about reclassification to Grade Group (GG) ⩾ 2. We hypothesized that simple and inexpensive clinical parameters could identify patients with indolent disease for whom less intensive monitoring is safe.
Methods
We analyzed upgrading to ISUP Grade Group (GG) ⩾ 2 in a large cohort of low-risk prostate cancer (PCa) patients on AS. We used mixed-effects logistic regression to develop a model predicting non-upgrading at the next follow-up biopsy, based on routine time-updated clinical-pathological variables.
Results
While annual reclassification persisted at a rate between 10.4% and 17.5% up to the 7th year, upgrades were predominantly GG2. Routine parameters powerfully stratified risk. Patients with a very unfavorable Prostate Specific Antigen (PSA) doubling time had a 40.5% upgrading rate versus 9.5% for those with a favorable value. The final model is based on baseline PSA density and number of positive cores, time-updated age and PSA doubling time category, detection of cancer in the last surveillance biopsy. The model showed moderate discrimination (0.73) in predicting non-upgrading.
Conclusions
Many patients on AS have indolent disease but steady upgrading justifies monitoring. A model using simple, routine parameters and PSA doubling time can identify those at minimal risk of reclassification, enabling a safe reduction in biopsy intensity. This advocates for a risk-adaptive AS protocol, reserving advanced tools like MRI or biomarkers for the few higher-risk cases.
Background: Active surveillance (AS) represents a cornerstone of personalized medicine in uro-oncology, offering an individualized management strategy for low- and selected favourable intermediate-risk prostate cancer that aligns treatment intensity with patient-specific risk profiles; however, real-world adherence data from southern European academic centres remain scarce. This study aimed to evaluate AS discontinuation rates, reasons for transition to active treatment, and quality of life (QoL) in a single-centre Greek university hospital cohort. Methods: This is an observational retropective cohort study of patients enrolled in an AS protocol at the First Department of Urology, Aristotle University of Thessaloniki, between October 2016 and July 2022. Treatment-free survival (TFS) was estimated using Kaplan–Meier analysis. Associations between AS discontinuation and age at diagnosis, PSA level, and Charlson Comorbidity Index (CCI) were explored using univariable and multivariable Cox proportional hazards regression. QoL, erectile function, and anxiety were assessed cross-sectionally in patients remaining on AS using SF-12, IIEF-6, STAI-6, and MAX-PC. Results: Thirty-six patients were included (32 low-risk; 4 favourable intermediate-risk), with a median age of 69.5 years, median PSA of 6.92 ng/mL, and median CCI of 3. After a median follow-up of 24 months (IQR 21–45), 19 patients (52.8%) transitioned to active treatment; the median time to treatment was 21 months (IQR 17–34). Among the 10 patients with a known reason for discontinuation, 6 (31.6% of all discontinued) showed histopathological or clinical disease progression, 3 (15.8%) had a PSA increase alone, and 1 (5.3%) transitioned due to urinary symptoms; the reason was unknown in 9 cases (47.4%). In exploratory Cox regression, PSA ≥ 7.0 ng/mL was the only factor with complete documented output significantly associated with transition to active treatment (univariable HR 3.70, 95% CI 1.35–10.1, p = 0.011; multivariable HR 3.93, 95% CI 1.42–10.9, p = 0.008). Cross-sectional QoL assessment in 10 patients remaining on AS demonstrated median scores above established population norms for SF-12 and below clinical anxiety thresholds on STAI-6 and MAX-PC. Conclusions: In this single-centre cohort, AS discontinuation occurred early and at a rate higher than that of established international programmes, consistent with the institution’s initial AS experience. Higher PSA at diagnosis was the only factor with complete analytical documentation to be significantly associated with earlier transition.
I. Mykoniatis, Athanasios Papatzelos, Damianos Damon Dejan Nikolaou Nikolovski et al.· Journal of Personalized Medi...· 0 citations
Background/Aim: This study aimed to determine whether lesion visibility on magnetic resonance imaging (MRI) predicts rebiopsy outcomes during active surveillance for prostate cancer. Patients and Methods: We retrospectively analyzed data from 111 patients enrolled in the Prostate Cancer Research International Active Surveillance study (Japan) at Kagawa University (January 2010–February 2025). After excluding 19 patients who discontinued active surveillance within one year, 92 patients were included in the analysis. MRI findings were classified as visible [Prostate Imaging Reporting and Data System (PI-RADS) score ≥3] or invisible (score ≤2). We assessed the association between visibility and rebiopsy outcomes, defined as reclassification progression beyond active surveillance criteria or no cancer. Results: MRI was performed at diagnosis in 32.6% (n=32) of patients, at one year in 37.0% (n=34), and at four years in 47.7% (n=21). Lesion visibility at diagnosis was not associated with continuation of active surveillance compared with invisibility [median 43 months, 95% confidence interval (12-not available) vs. not available (17-not available), p=0.404]. However, at the 1-year rebiopsy, reclassification occurred significantly more frequently in patients with visible lesions than in those with invisible lesions (42.1% vs. 7.1%, p=0.047). Conversely, no cancer was more common in patients with invisible lesions (50.0% vs. 10.5%, p=0.019). Conclusion: At one year, a PI-RADS score ≥3 was associated with a higher risk of reclassification, whereas a score ≤2 was associated with a greater likelihood of no cancer on rebiopsy. These findings highlight the prognostic value of MRI in guiding active surveillance.
Yoichiro Tohi, Kenichi Tanaka, Takuma Kato et al.· In Vivo· 0 citations
Active surveillance (AS) has become the standard management strategy for low-risk localized prostate cancer in the general population because of its excellent long-term oncologic outcomes and its ability to reduce overtreatment [1,2]. However, its role in patients carrying a germline BRCA2 mutation remains uncertain. Indeed, BRCA2 is associated with an increased risk of prostate cancer, earlier onset, and more aggressive disease, with a higher risk of metastasis and poorer cancer-specific survival [1-3]. In this context, applying conventional AS criteria to this population raises a major question: does an apparently low-risk cancer in a BRCA2 carrier truly represent indolent disease, or a disease that may be underestimated at diagnosis? The 2024–2026 French CCAFU recommendations and the 2026 EAU guidelines acknowledge the unfavorable prognostic impact of BRCA2 while also emphasizing that no high-level evidence currently supports systematically excluding these patients from AS [1,2]. Available data mainly suggest an increased risk of reclassification in familial or hereditary settings, without definitive BRCA2-specific evidence [1,4]. As of 2026, AS may therefore be considered in highly selected patients, but only after rigorous initial characterization with multiparametric MRI and appropriate biopsy assessment, clear patient counseling, and intensified follow-up [1,2].
Y. Alaoui, O. Bentaleb, S. Lafdali et al.· Scholars Journal of Medical...· 0 citations
OBJECTIVE
Active surveillance (AS) is the preferred management for individuals with low-risk prostate cancer (PCa), but its role in intermediate-risk (IR) disease remains underreported. Given growing interest and published data, we performed an updated systematic review and meta-analysis to evaluate AS outcomes in selected patients with Gleason Grade Group (GG) 1-2 IR PCa.
METHODS
A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD420251138532). PubMed/MEDLINE, Embase, and Web of Science databases were searched for studies published up to September 2025 reporting outcomes of AS in IR PCa. Primary outcomes were AS discontinuation-free survival and GG ≥3 upgrade-free survival.
RESULTS
In total, 18 studies, including 3783 selected patients with IR PCa, were analyzed. Pooled AS discontinuation-free survival rates were 70% (95% confidence interval [CI] 62-78) at 3 years, 63% (95% CI 58-68) at 5 years, and 53% (95% CI 38-67) at 10 years. In analyses restricted to GG 2 cohorts, corresponding pooled estimates were 72% at 3 years, 56% at 5 years, and 40% at 10 years. GG ≥3 upgrade-free survival was 84% (95% CI 76-92) at 3 years and 78% (95% CI 65-91) at 5 years in all cohorts and 92% (95% CI 86-98) and 87% (95% CI 78-95) at 3 and 5 years in cohorts screened using multiparametric magnetic resonance imaging. No significant difference in AS discontinuation was observed between biopsy GG 1 and 2 (hazard ratio 1.08; 95% CI 0.86-1.35). Limitations include moderate risk of bias and heterogeneity across AS protocols.
CONCLUSIONS
Although long-term data are lacking, particularly regarding robust oncological outcomes, growing evidence suggests that AS appears oncologically safe in well-selected patients. Magnetic resonance imaging will play a key role in the appropriate selection and follow-up of patients.
Alessandro Uleri, L. Cella, T. Long-Depaquit et al.· BJU International· 0 citations
Background: In high-risk prostate cancer, the optimal timing of radical prostatectomy after diagnostic biopsy remains a clinically important issue. A real-world delay between diagnosis and radical treatment frequently occurs, raising concerns about potential disease progression in high-risk patients. Methods: We conducted a single-center retrospective study including patients with high-risk localized and locally advanced prostate cancer who underwent radical prostatectomy from January 2016 to January 2026. Patients were stratified according to biopsy-to-radical prostatectomy interval into two groups: <90 days or ≥90 days. Adverse pathological outcomes were defined as extraprostatic extension, seminal vesicle involvement, positive surgical margins and lymph-node involvement. Univariable comparisons and multivariable logistic regression analyses were performed to identify independent predictors of adverse pathology. Results: A total of 158 patients with high-risk prostate cancer were included, of whom 67 (42.4%) underwent open- or laparoscopic radical prostatectomy within 90 days after biopsy and 91 (57.6%) after ≥90 days. On univariable analysis, the rates of extraprostatic extension were 59.7% vs. 63.7% in the <90-day and ≥90-day groups (p = 0.606), seminal vesicle involvement was observed in 22.4% vs. 24.2% (p = 0.627), positive surgical margins in 35.8% vs. 39.6% (p = 0.632), and lymph node involvement in 6% vs. 5.5% (p = 0.999). In multivariable logistic regression, a biopsy-to-radical prostatectomy interval ≥90 days was not independently associated with extraprostatic extension (OR 1.38, 95% CI 0.68–2.77, p = 0.371), seminal vesicle involvement (OR 1.43, 95% CI 0.63–3.27, p = 0.391) or positive surgical margins (OR 1.31, 95% CI 0.66–2.62, p = 0.443). The number of positive biopsy cores independently predicted extraprostatic extension (OR 1.17, 95% CI 1.04–1.32, p = 0.008), while higher PSA independently predicted seminal vesicle involvement (OR 1.05, 95% CI 1.01–1.10, p = 0.025) and positive surgical margins (OR 1.05, 95% CI 1.00–1.10, p = 0.027). Conclusions: In this real-world cohort of patients with high-risk prostate cancer undergoing radical prostatectomy, no statistically significant independent association was detected between a biopsy-to-radical prostatectomy interval ≥90 days and extraprostatic extension, seminal vesicle involvement, or positive surgical margins. However, the confidence intervals remained compatible with potentially clinically meaningful differences, and residual confounding from clinician-driven prioritisation and unmeasured preoperative factors cannot be excluded. Therefore, these findings should not be interpreted as demonstrating equivalence or the safety of delaying surgery.
Lorand-Tibor Reman, O. Vida, C. Chibelean et al.· Diagnostics· 0 citations
Background/Objectives: Early detection of pancreatic cancer (PC) remains challenging due to the lack of effective screening tools. We aimed to develop a clinically applicable model to identify individuals at high risk of PC using routine health check-up data. Methods: In a 1:4 matched case–control study (111 cases and 439 controls) using data collected between 2010 and 2018, PC cases were defined as individuals diagnosed with PC within 2 years of a health check-up. A model was developed using conditional logistic regression and validated in an independent cohort of 52,043 individuals (40 PC cases; 2019–2021). Results: Five risk factors were identified: carbohydrate antigen 19-9 ≥ 39 U/mL, hemoglobin A1c ≥ 6.5%, alkaline phosphatase > 110 IU/L, weight loss ≥ 5%, and dyspepsia. A 12-point risk scoring system was constructed, with an area under the curve of 0.784 in the development and 0.841 in the validation cohort. At a threshold of ≥5, the high-risk group had a significantly higher 2-year incidence of PC than the low-risk group (2.56% vs. 0.047%; p < 0.001), a 54.76-fold risk enrichment, with a negative predictive value of 99.95% and a number-needed-to-follow of 39. Conclusions: This simple, validated model effectively stratifies short-term PC risk using routine data, potentially facilitating targeted surveillance in the general population.
Hyo Jeong Lee, Ji Seon Oh, Sehee Kim et al.· Diagnostics· 0 citations