Indian Journal of Urology
LETTER TO EDITOR
Year
: 2020  |  Volume : 36  |  Issue : 4  |  Page : 332--333

Re; Singh S, Patil S, Tamhankar AS, Ahluwalia P, Gautam G. Low-risk prostate cancer in India: Is active surveillance a valid treatment option? Indian J Urol 2020;36:184-90


Abhishek Pandey, Swarnendu Mandal, Manoj K Das, Prasant Nayak 
 Department of Urology, AIIMS, Bhubaneshwar, Odisha, India

Correspondence Address:
Dr. Swarnendu Mandal
Department of Urology, AIIMS, Bhubaneshwar, Odisha
India




How to cite this article:
Pandey A, Mandal S, Das MK, Nayak P. Re; Singh S, Patil S, Tamhankar AS, Ahluwalia P, Gautam G. Low-risk prostate cancer in India: Is active surveillance a valid treatment option? Indian J Urol 2020;36:184-90.Indian J Urol 2020;36:332-333


How to cite this URL:
Pandey A, Mandal S, Das MK, Nayak P. Re; Singh S, Patil S, Tamhankar AS, Ahluwalia P, Gautam G. Low-risk prostate cancer in India: Is active surveillance a valid treatment option? Indian J Urol 2020;36:184-90. Indian J Urol [serial online] 2020 [cited 2020 Nov 23 ];36:332-333
Available from: https://www.indianjurol.com/text.asp?2020/36/4/332/296766


Full Text



We appreciate the authors for generating indigenous data of low-risk prostate cancer patients. The current guidelines recommend active surveillance (AS) as the management modality of choice in low-risk prostate cancer patients.[1] This study by Singh S et al. reported a 50% risk of upgrading or upstaging in Indian males with low-risk prostate cancer undergoing radical prostatectomy, who were eligible for AS.

The staging was done using multi-parametric magnetic resonance imaging (mpMRI) or digital rectal examination (DRE), but the number of patients who underwent mpMRI was not mentioned. It would be interesting to note the rate of upstaging in patients initially staged using mpMRI. The use of DRE for staging may be the cause of a relatively higher rate of stage misattribution, as seen in this study.

In addition, the subset of patients with very low-risk disease (Epstein criteria, defined as one to two positive core, no core with a >50% involvement, and prostate-specific antigen density [PSAD] of <0.15) was not defined. Most contemporary guidelines make a distinction between low risk and very low risk. High-volume Gleason grade Group 1 prostate cancer, as reflected by higher PSAD, a higher number of cores involved, and an increased percentage of core involvement is associated with an increased risk of coexistent occult higher-grade cancer and grade misattribution.[2] Higher PSAD was significantly associated with both upgrading and upstaging in this study, further suggesting stage and grade misattributions in these patients. mpMRI and targeted biopsy substantially decrease the risk of under grading and would have been useful in this setting.[3]

In our opinion, low literacy, preconceptions about the meaning of cancer and poor compliance with follow-up regimes are the primary barriers to AS in low-risk patients in India, leading to a lack of indigenous data in this regard. Long-term follow-up with robust data on oncologic outcomes should be sought before recommending deviations from the current guidelines.

It was also interesting to note that although a single surgeon performed the surgeries, the manuscript mentions two separate surgical centers. The relative contribution of these centers toward the number of surgeries was not mentioned. Besides, which center reviewed the histopathology was also not clarified. This needs clarification.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

References

1Prostate Cancer: Clinically Localized Guideline - American Urological Association. Available from: https://www.auanet.org/guidelines/prostate-cancer-clinically-localized-guideline. [Last accessed on 2020 Aug 20].
2Mamawala MM, Rao K, Landis P, Epstein JI, Trock BJ, Tosoian JJ, et al. Risk prediction tool for grade re-classification in men with favourable-risk prostate cancer on active surveillance. BJU Int 2017;120:25-31.
3Ahmed HU, El-Shater Bosaily A, Brown LC, Gabe R, Kaplan R, Parmar MK, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): A paired validating confirmatory study. Lancet 2017;389:815-22.