Active surveillance in prostate cancer is possible for Afro-Caribbean population:

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ORIGINAL ARTICLE

Active surveillance in prostate cancer is possible for Afro-Caribbean population:

Comparison of oncological outcomes with a Caucasian cohort

La surveillance active du cancer de prostate est possible en population afro-caribéenne : comparaison des résultats oncologiques avec une cohorte caucasienne

M. Percot

^a^,∗

, G. Robert

^a

, F. Bladou

^a

, J.-M. Ferrière

^a

, H. Bensadoun

^a

, J.-C. Bernhard

^a

, E. Alezra

^a

,

G. Capon

^a

, C. Sénéchal

^b

, G. Gourtaud

^b

, L. Brureau

^c

, V. Roux

^b

, P. Blanchet

^c

, R. Eyraud

^b

aServiced’urologieettransplantationrénale,CHUPellegrin,placeAmelie-Raba-Léon,33000 Bordeaux,France

bServiced’urologieettransplantationrénale,CHUdePointe-à-Pitre/Abymes,97110 Pointe-À-Pitre,France

cCHUdePointe-à-Pitre,universitéd’Antilles,universitédeRennes,Inserm,EHESP,Irset (Institutderechercheensanté,environnementettravail)-UMRS1085,97110

Pointe-à-Pitre,France

Received27March2020;accepted17May2020 Availableonline24June2020

KEYWORDS Activesurveillance;

Afro-Caribbean;

Prostatecancer;

Lowrisk

Summary

Background.—ProstatecancerissupposedlymoreaggressiveamongAfro-Caribbeanmen.There isalackofdatainthispopulationforactivesurveillance.Publishedseriesareretrospective orhavesmallsamplesandresultsarediscordant.Theobjectivewastodeterminatewhether actualactivesurveillancemodalitiescanbeappliedforAfro-Caribbeanmenbycomparingtheir oncologicaloutcomeswithCaucasianmen.

∗Correspondingauthor.

E-mailaddress:percot.melanie@gmail.com(M.Percot).

https://doi.org/10.1016/j.purol.2020.05.006

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Methods.—Atotalof449consecutivepatientswhounderwentactivesurveillanceforfavorable- riskprostatecancerintwoFrenchUniversity-Medical-Centersbetween2005and2018:261in Guadeloupe,FrenchWest Indies,and188inBordeaux,metropolitan France.Medianfollow- upwas56months,(95%CI[32—81])and52months(95%CI[30—75]),respectively(P=0.07).

Curative treatmentwas given incase ofhistological, biological, orimaging progression, or uponpatientdemand.Primary endpointsweretreatment-free,overallandspeciﬁcsurvival.

Secondaryoutcomeswerereasonsofdiscontinuatingactivesurveillance,histologicalpoorprog- nosisfactorsafterprostatectomy,CAPRA-Sscore,biochemical-recurrence-freeaftertreatment andmetastasis-freesurvival.Kaplan—Meiermethodwasused.

Results.—Mediantreatmentfreesurvivalwas58.4months(CI95%[48.6—83.1])forACMand notreachedat120monthsforCM(P=0.002).Overallsurvival(P=0.53),andspeciﬁcsurvival (P=0.21) were similar inthetwo groups.CM were likelyto havepoorprognosis factor on prostatecomypiece(57vs30%,P=0.01).NodifferenceforrepartitionoftheCAPRA-Sscore (P=0.86),biochemical-recurrence-free(P=0.92)andmetastasis-free(P=0.44)survival.

Conclusions.—OncologicaloutcomesforactivesurveillanceofAfro-CaribbeanandCaucasian menweresimilarintermsofmortality,recurrenceandmetastasisinourbicentricstudy,showing usabilityofcurrentcriteriaforAfro-Caribbean.Thehigherrateofdiseaseprogressioninthe Afro-Caribbeanpopulationrequiresclosemonitoring.

Levelofevidence.— 3.

MOTSCLÉS Surveillanceactive; Afro-caribéen; Cancerdeprostate; Faiblerisque

Résumé

Introduction.—Lecancerdeprostate(CaP)estd’agressivitésupposéeplusimportantechez leshommesafro-caribéens,avecpeudedonnéesconcernantcettepopulationensurveillance active(SA).Objectif:comparerl’évolutionetl’agressivitédesCaPenSAdespatientsd’origine Afro-caribéenneparrapportauxpatientsd’originecaucasienne.

Méthodes.—Étudebicentriquede449patientsenSApourunCaPderisquefavorableentre2005 et2018:261enGuadeloupe,Antillesfranc¸aises,et188àBordeaux,Francemétropolitaine.Le suivimédianétaitrespectivementde56(IC95%[32—81])et52(95%IC[30—75])mois(p=0,07).

Untraitementcuratifétaitappliquéencasdeprogressionhistologique,biologique,àl’imagerie, etparsouhaitdupatient.Lescritèresdejugementprincipauxétaitlasurviesanstraitement, globaleetspéciﬁque.Lescritèressecondairesétaientlesraisonsd’arrêtdesurveillance,les critèresdemauvaispronosticaprèsprostatectomie,leCAPRA-Sscore,lessurviessansrécidive biologiqueetsansmétastases,utilisantlaméthodedeKaplan—Meier.

Résultats.—Lamédianedesurviesanstraitementétaitde58,4mois(IC95%[48,6—83,1])pour legroupeAntillaisetnonatteinteà120moispourlegroupecaucasien(p=0,002).Lasurvie globale(p=0,53)etspéciﬁque(p=0,21)étaientcomparablesdansles2groupes.Laprésence decritèredemauvaispronosticsurpiècedeprostatectomieétaitplusrépanduedanslacohorte caucasienne(57%vs30%,p=0,01).AucunedifférenceentermesdeCAPRA-Sscore(p=0,86), surviesansrécidivebiologique(p=0,92)etsansmétastases(p=0,44).

Conclusion.—Les résultatsoncologiquessont comparablesentermesdemortalité,récidive et métastases pour ces deux populations, montrant la possibilité de la SA en population caribéenne.Toutefois,letauxplusimportantdeprogressiontumoralenécessiteunesurveil- lancerapprochée.

Niveaudepreuve.— 3.

Introduction

Prostatecancer (PCa) is the second most commoncancer and the ﬁfth leading cause of cancer death among men worldwide[1].Thedevelopmentofindividualscreeninghas helpedtodecreaseitsspeciﬁcmortalityatthecostofover-

diagnosisof indolentforms [2]. Activesurveillance(AS) is an important option in the managementof localized PCa withalowriskofprogression[3].Itisproposedforasymp- tomaticpatients ina goodgeneral state of health witha lifeexpectancyofmorethan10years.Theaimofthiscon-

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servativestrategyistodelaycurativetreatment,whichcan beassociated with morbidity and a poorerquality of life [4]. Tumor progression needs to be closely monitored to remain curable in case of an unfavorable evolution. The oncologicalsafetyofAShasbeenconﬁrmedinseverallarge international series witha long-term follow-up, up to 20 years [5—7]. Selection criteria for eligible patients have beenvariable,dependingonseries[8].Theywerebasedon theresultsofadigitalrectalexam,prostaticspeciﬁcanti- gen (PSA), Gleason score, and tumoral volumeon biopsy.

Some studies also took PSA density (PSAd) into account.

Mostused narrow criteria, inspired by the Johns Hopkins Hospitalcohort[9],butASisalsoapplicabletoalllowrisk PCa[10].Currentguidelinesaremainlybasedondatafrom Caucasianmen[11].However,theAfro-Caribbean popula- tionis known tohave a differentepidemiology, withone ofthehighestincidenceandmortalityratesforPCaworld- wide[1,12].This disparityis explainedbyseveralfactors, notablyAfricanethnicoriginandchlordeconeexposure[13].

The incidence, progression, and mortality rates between theAfro-CaribbeanandAfro-Americanpopulations,aswell as that of sub-Saharan African descent, are similar [14].

The rate of tumor progressionappears tobe higher, with a poorer prognosis, poorer histological characteristics of surgical samples,and a higherrate of biochemical recurrence after prostatectomy for patients with low-risk and verylow-riskPCainAS.However,theresultsarediscordant, andsome studieshaveshownnodifferences[15,16].Most serieshave consistedofthe analysisof retrospectivedata ofprostatectomiesoflow-riskpatientswhodidnotundergo AS.InprospectivestudiesofAS,menofsub-SaharanAfrican descenthaveoftenbeen underrepresented[17].Further- more,thereisnoproofofpersistentdisparityafteradjusting fordemographiccaracteristicsatinclusion,typeofchosen treatment,andsocio-economicstatusofthepatient[3].The absenceofdataforthispopulationdoesnotallowthemod- iﬁcationofinclusionorfollow-upmodalities[11].Here,we soughttoevaluateevolutionandaggressivityofPCainASin theAfro-Caribbeanpopulation,andcompareittothatofthe Caucasianpopulationwithequalaccesstomedicalcare.We analyzedtwoprospectiveFrenchcohortsfromtheUniversity MedicalCenter(UMC)ofPointe-à-Pitre,WestFrenchIndies, andUMCofBordeaux,MetropolitanFrance,todeterminate whethercurrentcriteriaareusableformenofsub-Saharan descent.

Patients and methods Population

Atotal of449 consecutive patients wasenrolledin an AS protocol.261 men wereincluded in the UMC ofPointe-à- Pitre(Afro-Caribbeangroup)betweenMarch2005andMay 2018.188menwereincludedintheUMCofBordeaux(Cau- casian group) between December2006 and May 2018. All patientswerediagnosedwithalocalizedPCa,mostlyofvery lowrisk,deﬁnedbytheFrenchcriteriaasPSA≤10ng/mL, Gleason score of 6 (3+3), and less than three positive cores, with a maximal invasion of 3mm per core. Some selectedpatientsofloworfavorableintermediateriskwere alsoincluded, afteramultidiscplinaryoncologicconcerta-

tionmeeting.Low riskwasdeﬁnedasPSA≤10ng/mLand Gleason score6(3+3);favorableintermediateriskasPSA between 10 and 20ng/mL or Gleason score of 7 (3+4).

Patientswerefollowedwithdigitalrectalexameach year and measurement ofPSA blood levels each sixmonths. A systematicsecondprostatebiopsywasperformedbetween6 and18monthsafterprostaticandpelvicmagneticresonance imaging (MRI) for histological conﬁrmation. Reevaluation biopsieswereperformedeach2years.Pelvicandprostatic MRIwere interpretedby anexperienced radiologist,using thePI-RADSscore,showingasigniﬁcantlesionwithascore between3and5.CriteriafordiscontinuitingASwerebiologi- calprogression(PSAdoublingtime<36months),anincrease in tumoral lenght core invasion(more than 3mm or than 50% per core), more than two positive biopsies, a Glea- sonscore≥3+4,MRIprogressionorrequestofthepatient.

Variouscurative treatmentswereproposedaftermultidis- cplinary oncological concertation, based on the data of clinical, biological, histologicalandMRI progression: radicalprostatectomy(RP),radiotherapy,androgendeprivation therapy(ADT).Concerningfocaltherapy,brachytherapywas onlypracticed inBordeauxandHigh-IntensityFocal Ultra- sound(HIFU)startedinPointe-à-Pitrein2018.

Statistical analysis

Primary endpoints were treatment-free (TFS), overall (OS) and specific (SS) survival for all patients, by the Kaplan—Meiermethodforbothpopulations.Secondaryend- points were biochemical -recurrence-free survival (BRFS) after prostatectomy and after all treatment, and metastasis -free survival for all patients by the Kaplan—Meier method, the presence of poor prognosis factors and the CAPRA-Sscore.Biochemicalrecurrencewasdefinedastwo PSA>0.2ng/mLafterRP,and/orPSA≥Nadir+2ng/mLafter radiotherapy or focaltreatment. Histologicallypoor prognosis factors for surgical samples were defined as≥pT3a (upstage),pN+,Gleason>3+4and/or R+status.Biochem- icalrecurrencerisk(BRR)afterRPwasevaluatedwiththe CAPRA-Sscore,basedonpre-operativePSAlevels,Gleason score,surgicalmargins,seminalvesicleextension,andlym- phaticinvasionassessedbysurgery.BRRwasconsideredto belowforaCAPRA-Sscorefrom0to2,intermediateifitwas from3to5,andifitwas≥6.Dataareexpressedinmedian, IQR(25—75%)andfrequency(%).Categoricalvariableswere comparedusingtheExactFisherTestandcontinuousvaria- bleswiththeMannWhitneyTest.Survivalswerecompared withthelog-ranktest.Statisticalanalyseswereperformed usingjmppro^®9.0,SASinc.,(SAScampusdrive),Cary,North Carolina.

Results Population

Thebaselinecharacteristicsweresimilarbetweenthetwo groups (Table 1).Medianage was65.6 and64.6 yearsfor ACMandCM(P=0.18).91.2%ofACMwereclassiﬁedaslow risk,versus91.5%forCM(P=0.07).Medianfollow-upwas56 months,(95%CI[32—81])and52months(95%CI[30—75]), respectively (P=0.07),witha maximumfollow-up of 13.2

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Table1 Demographic,clinical,biological,histological,MRIcharacteristics.

Bordeaux Pointe-à-Pitre P

Medianage(year) 64.6[60.7—67.5] 65.3[59.8—70.1] 0.18

MedianPSA(ng/mL) 6.24[4.7—8.07] 5.82[4.39—7.61] 0.27

PSAdensity≤0.15,n(%) 128(70.72) 164(62.84) 0.08

Gleasonscoreonbiopsy,n(%)

4 1(0.53) 3(1.15)

5 3(1.60) 9(3.45)

6 182(96.81) 243(93.10) 0.40

7(3+4) 2(1.06) 6(2.30)

>2positivesbiopsies,n(%) 7(4.43) 18(6.95) 0.29

Medianbiopsictumorallength(mm) 1[0.6—2] 1[1—3] 0.0004

cT2,n(%) 21(11.17) 46(17.62) 0.06

MRIrealised,n(%) 146(77.66) 204(78.16) 0.90

LesiononMRI,n(%) 105(72.41) 156(76.85) 0.10

Lostoffollow-up,n(%) 12(6.38) 15(5.75) 0.77

Figure1. Flowchart.

and10.9years,respectively.Duringthisperiod,67%ofCM versus48%ofACMremainedonAS(Fig.1).

Treatment

ComparisonofTFSbetweenbothpopulationsisexposedin Fig.2. MedianTFS was58.4 months(CI 95% [48.6—83.1]) forACMandnotreachedat120monthsforCM(P=0.002).

ThereasonsfordiscontinuatingASweresimilarinthetwo groups, in terms of biological and MRI criteria. Concern-

inghistologicalcriteria,therewasasigniﬁcativedifference in the increase of tumoral lenght for 53% of ACM versus 37.1%ofCM(P=0.04)(Table2).ACMweremorelikelythan CM to experience disease progression (OR=2.09; CI 95%;

[1.39—3.15]).Mostpatientswhounderwenttreatmenthad aRP upon discontinuating AS:81.9% of ACMand60.8% of CM.Focaltreatmentwasgivento23.5%ofCMversus1.75%

ofACM(P=0.0003).ForpatientstreatedbyRP,thepropor- tionwithoneorseveralpoorhistologicalprognosticfactors inthesurgicalsampleswasgreaterforCMthanACM,57.1%

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Figure2. Treatment-freesurvivalinactivesurveillance-Kaplan—Meiercurve.

Table2 Characteristicsattheendofactivesurveillance.

ReasonsofASending,n(%)

Patientdemand 4(6.45) 12(9.09) 0.53

PSAdoublingtime<36months 29(46.77) 50(37.88) 0.24

Biopsicprogression 34(54.84) 87(65.91) 0.14

Gleasonprogression 24(38.71) 51(38.64) 0.99

Numberofbiopsyprogression 19(30.65) 51(38.64) 0.28

Increaseofbiopsictumorallength 23(37.10) 70(53.03) 0.04

MRIModiﬁcation 8(12.90) 10(7.58) 0.23

Typeoftreatment,n(%)

Radicalprostatectomy 31(60.78) 95(81.90)

Radiotherapy 4(7.84) 13(11.21)

AndrogenDeprivationtherapy 1(1.96) 1(0.86)

HIFU 11(21.57) 2(1.72) 0.0003

Brachytherapy 1(1.96) 0(0)

Associationradiotherapy+ADT 3(5.88) 5(4.31)

versus29.9%(P=0.01)(Table3).The frequencyofupstag- ingwasgreaterforCMthanACM,with39.29%ofpT3stage versus 14.95% (P<0.0001). There wasnosignificative dif- ferenceinupgradebetweenthetwogroupsrelativetothe initialbiopsy(P=0.13).Therewasalsonosignificativedif- ferencebetween the twopopulationsfor stratification by theCAPRA-Sscore(P=0.86),withlowBRRfor57.5%ofACM versus57.1%ofCM(Table3).

Mortality and metastasis

OS (P=0.42) and SS (P=0.21) were similar in the two groups(Fig.3).ThreeACMpatientsdiedfromcardiovascular eventsandonefrompancreaticcancer. OneCMdiedfrom infection afterprostatectomy. MFS was not signiﬁcatively differentbetweenthetwogroups(P=0.62)(Fig.4).Inthe Afro-Caribbeangroup,twopatientsshowed bonelocaliza-

tion.OnemanhadrecurrenceafterRP,withalowCAPRA-S scoreand averylow risk atdiagnosis. The diseaseof the other evolvedduringAS.He hadafavorableintermediate riskatdiagnosis.IntheCaucasiangroup,twopatientswith aninitiallyverylowriskdevelopedmetastasesduringAS.

Biochemical recurrence

BRFS were similarafter alltreatment (P=0.92) and after prostatectomy(P=0.92)(Fig.5).AmongthenineACMwho hadrecurrenceafterRP,fourweretreatedwithradiother- apy,onehadonlyradiotherapy,anothersacombinationof radiotherapyandADT,andthreehadnotyetreceivedtreat- ment.FourCMhadarecurrenceafterRP.Threeweretreated withradiotherapyandonehadcombinationofradiotherapy andADT.RecurrenceafterHIFU wastreatedbyRPforone patientandtwohadnotyetreceivedtreatment.

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Table3 Anatomo-pathologicalanalysisafterprostatectomy.

pTstage,n(%)

pT2 17(60.71) 74(85.06)

pT3a 11(39.29) 6(6.90) <0.0001

pT3b 0(0) 7(8.05)

pNstage,n(%)

pNx 9(32.14) 29(33.33)

pN0 18(64.29) 56(64.37) 0.93

pN1 1(3.57) 2(2.30)

R±,(n%) 4(14.29) 22(25.29) 0.22

Gleasonscore,n(%)

6 10(33.33) 39(44.83)

7(3+4) 11(37.04) 31(35.63)

7(4+3) 6(18.52) 17(19.54) 0.40

8 2(7.41) 0(0)

9 1(3.70) 0(0)

1ormorepoorprognosisfactor,n(%) 16(57.14) 26(29.89) 0.01

Capra-Sscore,n(%)

1 16(57.14) 50(57.47)

2 10(35.71) 28(32.18) 0.86

3 2(7.14) 9(10.34)

Upgradesurgerysamplerelativetoinitialbiopsy,n(%) 20(71.43) 48(55.17) 0.13

Figure3. OverallandSpeciﬁcsurvival.

Discussion

AShasamajorroleinthemanagementoflow-riskPCa.How- ever, moststudieshave beencarriedoutin theCaucasian population [17]. Anumber of retrospective or smallsam- pleseriessuggestmoredefavorableoutcomesforlow-risk PCainpatientsofAfricanethnicorigin[18,19].Theaimof ourstudywastoscreentheevolutionandaggressivenessof favourable-riskPCaonASintheAfro-Caribbeanpopulation throughadirectcomparisonwithaCaucasianpopulation.

Our results demonstrate a higher rate of curative treatment for Afro-caribbean men (ACM), with a median treatment-freesurvivalof58monthsversusnotreachedat 120 monthsfor Caucasianmen(CM). Two Americanseries ofASshowedthatblackracewasapredictoroftreatment fordiseasecharacteristics[20,21].Wefoundtwo-foldhigher riskofprogressioninACM.Inamulticentricstudy(Detroit, Cleveland,Guadeloupe),thatcomparedGuadeloupeanand CaucasianAmericanmenonAS,duringathree-yearfollow- up, the proportion of patients remaining on AS was 66%

versus82%, respectively, withaprogressionratethat was fourtimeshigherintheCaribbeangroup[19].DebasishSundi et al. reported three time more histological progression infollow-upbiopsyforAfro-AmericanmenthanCaucasian patients[22].Ourresultsandthesedatahighlighttheimpor- tanceofclosefollow-upforpatientsofAfricanethnicorigin onAS.

ASisstillanimportantoptionforpatientsofsub-Saharan Africandescent,despitethe aggressivefeatures ofPCain thispopulation.Overallandspecificsurvivalwereexcellent andcomparableinthetwogroups,withnospecificmortality fromPCaintheAfro-Caribbeangroupandonlyonedeathin theCaucasian group froma post-operativeinfection. The rateofmetastasisforallpatientswasalsoacceptable,with lessthan3%ofotherlocalizationsforbothpopulationsafter 5yearsoffollowup.WerecentlyrapportedsecurityofASfor ourpopulation,in aprospectivestudy,incomparisonwith internationalpublished data[23]. With selectedpatients, specific survival was100% witha metastasis rate of 0.4%

overfour-yearsmedianfollow-up.Inthisbicentricstudy,we

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Figure4. Metastasis-freesurvival.

Figure5. Biochemicalrecurrence-freesurvivalafterRPandafteralltreatments.

conﬁrmedthatglobal,speciﬁcandmetastasis-freesurvival arethesameinthetwocohorts.

Tumoral aggressivity after prostatectomy in Afro- Americanpatients is stilla contentious topic. Most series screening for poor prognosticfactors after prostatectomy retrospectively analyzed surgery samples of patients who wouldhavequalified for AS.Afro-Americanmenaremore likely to have defavorable outcomes after surgery, with higher upgrading and upstaging rates, than their white Americancounterparts [24—26]. A recent study from the SEARCH database, with a large number of Afro-American men who had the same access to healthcare did not findany significativedifference between thetwo popula- tionsintermsofhistologicalreclassificationorbiochemical recurrence after immediate prostatectomy [15]. In con- trast, ourseries showed moreupstaging in theCaucasian cohort. This could be explained by a different repartition of curative options to treat localized PCa in the

twocenters. Indeed,20% oftreated patients in Bordeaux were offered HIFU or brachytherapy, generally proposed for smaller tumoral lesion than prostatectomy. The other 60% of treated patients had a surgical treatment, versus 80%in Guadeloupe,wherefocal treatmentshave only lately become available. Nevertheless, the repartition of poorprognosticfactorsaccordingtotheCAPRA-Sscoreand biochemical-recurrence-free survival after prostatectomy andalltreatmentswerecomparable,withaﬁve-yearsbio- chemicalrateoflessthan15%forbothgroups.

Several studies suggest that the higher reclassiﬁcation rateofAfricandescents mayberelatedtothemoreante- riorlocalizationofsigniﬁcanttumorsfoundinprostatectomy samples[27].Thiswouldleadtounder-diagnosisbystandard echo-guidedprostatebiopsy.In2018attheUMCofGuade- loupe, we analysed prostatic MRI before targeted biopsy [28].ACMdidnothavemoreanteriorlesions(2%,)incontrast totheAmericanseries.TargetedbiopsybyMRI-fusion(Koelis

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system^®),has been practiced since 2017 in both centers.

Biopsies werepreviously performed withcognitive fusion.

Mageret al.showeda learningcurve for targetedbiopsy, withbetterdetectionafter42procedures[29].Bothcenters wereatthebeginningoftheexperienceduringthestudy.

Ourstudyhadseverallimitations.Ethnicstatisticsarenot allowedinFrance.Thus,thetwogroupswerenotallocated accordingtotherace,buttowherethepatientslive.Itis commonlyadmittedthat morethan80%ofthepopulation isofAfricandescent[12].ThegreaterincidenceofPCain thispopulationsuggestsalargerproportionofACMin this cohort. This wasa retrospective analysis of prospectively collecteddata.Therewasnoprospectiveprotocol,although theinclusionandfollow-upcriteria, aswell astreatment, wereverysimilar.Thiswasalsoabicentricstudy,withno central pathological or imaging review, which couldhave causedabiasofhistologicalandMRIinterpretation.

The strength of this study is the large proportion of ACM,whorepresented58%ofthetotalcohort.Thesemen have the same accesstoFrench healthcare asmetropoli- tanpatientsintermsofdiagnosisandtreatmentofalltype ofdiseases, removing anysocio-economicfactors.Clinical and pathologicfeatures were comparableat inclusion for thetwogroupsandthecriteriausedfordiscontinuatingAS werethesame,basedonFrenchguidelines.

Conclusion

For selected patients with the same access to healthcare,tumourprogressioninpatientsunderASforlocalized prostate cancer was higher for ACM. Treatment-free survival was thus shorter than for CM. However, short- and medium-term oncological outcomes concerning mortality, recurrenceandmetastasisweresimilarforthetwogroups.

Furthermore,wedidnotobservemoreunfavorablefeatures insurgicalsamplesforACM.Currentrecommendedmodali- tiesofAScanthusbesafelyappliedforallACM,iftheyare closelymonitored.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

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