What were the consensus statements on the follow-up protocol for subsequent years and when should active surveillance be stopped?

Active surveillance follow-up protocol:

Men on active surveillance should have access to a clinical specialist nurse. They should be offered and have access to support/counselling during their time on active surveillance.

Follow-up protocol during the second and subsequent years of active surveillance:

• Men should be provided with an updated personalised active surveillance plan that should be communicated to their GP.
• A repeat PSA test should be done in line with the recommended PSA interval and threshold* communicated by the patient’s urology consultant within the personalised active surveillance plan.
• If a patient’s individualised PSA threshold is breached, then the GP should check a midstream urine specimen for infection, and re-check the PSA level after six weeks if the urine sample is negative for infection. If the PSA threshold remains breached, the GP should refer the patient for further diagnostic tests.
• A repeat mpMRI scan should be considered if a lesion was visible at baseline or the PSA rises and breaches the individualised PSA threshold.
• DRE should be considered on an individual basis.
• A repeat biopsy should be offered when mpMRI shows a suspicion of progression.
• Clinical assessment of suitability for radical treatment should be reviewed periodically.

* The factors that will influence a patient’s PSA interval could include PSA history, mpMRI results and PSA density.

When to stop active surveillance:

The decision to move from active surveillance to radical treatment should be made in light of the individual man’s personal preferences, in addition to clinical features, co-morbidities, functional impairment (i.e., the e-Frailty index) and life expectancy.

DRE, digital rectal examination;  mpMRI, multi-parametric magnetic resonance imaging; PSA, prostate-specific antigen. Note: The expert reference group did not reach a consensus on a specified frequency of repeat biopsy for men on active surveillance. Instead, they agreed that this could be informed by evidence of change in PSA or mpMRI findings.

References:

1. Merriel S et al. BJU Int 2019; doi: 10.1111/bju.14707. [Epub ahead of print].