The 5-year results of the Stratified Cancer Active Surveillance programme for men with prostate cancer

Objectives

To report 5-year outcomes from the STRATified CANcer Surveillance (STRATCANS) programme based on progression risks using National Institute for Health and Clinical Excellence (NICE) Cambridge Prognostic Group (CPG) at diagnosis, prostate specific antigen density and magnetic resonance imaging (MRI) visibility.

Patients and Methods

Men with CPG1 and CPG2 disease selecting active surveillance (AS) were included into STRATCANS and allocated to one of three increasing follow-up intensities. Outcome measures were: (i) treatment for CPG≥3 progression (main outcome), (ii) any treatment, (iii) conversion to watchful waiting (WW), (iv) patient self-attrition, and (v) mortality.

Results

A total of 297 men (median age 66.0 years) were reviewed. The median (interquartile range, mean) follow-up for men still on AS was 4.9 (2.7–7.6, 5.3) years. In the cohort, 38.0% were CPG2 and 25.0% Grade Group (GG) 2 at AS entry. Overall, 214/297 (72.1%) remained treatment free: 158 (53.1%) were still on AS, 17 (5.7%) died of other causes, and 39 (13.1%) progressed to WW/discharge. Only 10 (3.4%) left AS from anxiety. There were no cancer deaths or metastatic events. In all, 80 men (26.9%) converted to treatment due to biopsy/MRI progression but only 35 (11.7%) of these reached CPG≥3 disease. Treatment for CPG≥3 occurred in 7.6% of CPG1 and 18.5% of CPG2 disease and 9.9% of GG1 and 17.5% of GG2 disease. By STRATCANS tier, treatment for CPG≥3 disease was 4.7% in STRATCANS 1, 12.9% in STRATCANS 2, and 27.4% in STRATCANS 3 (P < 0.001). STRATCANS had an area under the curve (AUC) of 0.74 for predicting CPG≥3 progression out-performing stratification by GG (AUC 0.64), CPG (0.69) and Likert score (0.51) alone or a combination of MRI visibility and GG (0.64). Longitudinal data have allowed further refinement of the STRATCANS schedule.

Conclusions

The STRATCANS 5-year outcomes demonstrate that a simple risk stratified surveillance using a prognostically meaningful endpoint is safe, durable, has low treatment rates, high patient compliance and appropriately tailors monitoring based on risks of progression. A website and implementation toolkit are now available.