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Transition from active surveillance to observation in prostate cancer patients older than 75 years. A long follow-up series
Transición de vigilancia activa a observación en pacientes mayores de 75 años con cáncer de próstata en una serie de largo seguimiento
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A long follow-up series" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "378" "paginaFinal" => "383" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "G. Fernández-Conejo, E. de la Peña, V. Hernández, E. Pérez-Fernández, C. Llorente" "autores" => array:5 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Fernández-Conejo" "email" => array:1 [ 0 => "gfernandezc@fhalcorcon.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "de la Peña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "V." 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"apellidos" => "Llorente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Investigación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Transición de vigilancia activa a observación en pacientes mayores de 75 años con cáncer de próstata en una serie de largo seguimiento" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1543 "Ancho" => 2500 "Tamanyo" => 145031 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Percentage of world population over 60 years old versus total population: 1950–2050.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The estimated incidence for the most frequent tumor among Spanish men in 2017 places prostate cancer (PC) on the first place, with 30,076 new cases. The data from GLOBOCAN 2012,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> distributed by age and sex, and extrapolated to data from the Spanish population for 2017 provided by the INE (National Statistics Institute), also provide a 5-year estimate of 104,405 cases, with a prevalence following breast cancer.</p><p id="par0010" class="elsevierStylePara elsevierViewall">However, the tumors causing the highest number of deaths in 2016 in Spain among the general population were lung cancer (22,187 deaths) and colorectal cancer (15,802 deaths), followed by a large distance from pancreatic cancer (6789 cases), breast cancer (6477 deaths) and, far behind, prostate cancer (5752 deaths).</p><p id="par0015" class="elsevierStylePara elsevierViewall">This difference between incidence, prevalence and cancer deaths requires the design of therapeutic strategies aiming to minimize side effects and searching for more adjusted treatments for the – usually elderly – population that will suffer from this disease.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is unquestionable that treatments with curative intent through surgery or radiotherapy (RT) are the required therapeutic tools for localized PC. However, none of the 3 options is free of complications and/or undesirable side effects. In this way, a more conservative option called active surveillance (AS) has been increasingly consolidated in the last decade.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It is not easy for urologists to know when and how to perform the transition (with the corresponding invasive tests and economic costs) of patients from AS to observation, due to the slow natural development of the disease or the simple fact that the AS program includes patients for long periods of time (when new morbidities such as cardiovascular, respiratory diseases, etc. arise). This situation is complicated if we take into account that observation is a follow-up strategy applied to patients with a limited life expectancy.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objectives</span><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of the study is to analyze the results of an AS program in low risk PC men who were included at the age of 75 years or more or have reached this age throughout their inclusion in the program, evaluating the treatments that have been performed.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and method</span><p id="par0035" class="elsevierStylePara elsevierViewall">A prospective cohort of patients included in AS was studied at the Foundation University Hospital in Alcorcón, between 1999 and 2018.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study population</span><p id="par0040" class="elsevierStylePara elsevierViewall">A cohort of patients diagnosed with very low risk PC<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> (PSA<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng/ml, Gleason 6, <3 affected cylinders, <50% cylinder affectation and cT1-2a), included in the AS program with an age over 75 years, was selected from the total series between 1999 and 2018. In addition, the study has included several patients with low/intermediate risk criteria, with ISUP group 2 Gleason. These criteria have not been modified during the inclusion of patients in the entire series.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Follow-up protocol</span><p id="par0045" class="elsevierStylePara elsevierViewall">After inclusion in the AS program, a new determination of PSA and a multiparametric magnetic resonance (in the most recent cases in the series) is performed 6 months after diagnosis. Subsequently, a follow-up biopsy is performed after one year. A follow-up visit including PSA levels and rectal examination is performed every six months. The biopsies are carried out once or twice a year, according to the patients and their clinical-analytical results.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Observation patients have PSA tests every six months. This frequency may vary if the patient presents stable PSA values during follow-up, increased comorbidity or at the patients’ request.</p><p id="par0055" class="elsevierStylePara elsevierViewall">AS exit is proposed in cases of anatomopathological, clinical, radiological progression or when it is the patient's wish. An increased PSA value is not a strict criterion for leaving active surveillance in our case. However, if this rise occurs together with another circumstance, this may lead to the patient's exit from the program.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The morbidity of those who received curative treatment and those who would transition to observation was determined at the entry and exit from the AS program, using the Charlson scale.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">A descriptive analysis of the series was performed, and changes in the Charlson index were compared in both groups through a Wilcoxon test. In addition, the comorbidity differences between the patients from the curative treatment group and the observation group were compared using a Mann–Whitney <span class="elsevierStyleItalic">U</span> test. We assessed progression-free and cancer-specific survival with Kaplan–Meier curves. The SPSS package, version 19.0 was used for the entire analysis.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">From an AS series of 346 patients, we have analyzed a cohort including 90 cases that met the age criteria previously described. Of these, 15 (16.7%) were at intermediate risk: 7 with Gleason 7 (3<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>4), 6 with more than 2 affected cylinders and another 2 with a percentage of the affected cylinders greater than 50%. A multiparametric magnetic resonance was performed on these 15 (16.7%) patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The median follow-up was 6.4 years. 72 patients (80%) reached 75 years of age during follow-up, with a median (interquartile range) age at diagnosis of 72.8 (73.9–70) years. Seventy-one patients (78.9%) had a Charlson score <2.</p><p id="par0080" class="elsevierStylePara elsevierViewall">43 (47.8%) patients are still under AS. There were 40 (44.4%) who left AS and 7 (7.8%) lost to follow-up while in AS. The reasons that justified the withdrawal of the AS program were: pathological progression in 21 cases (23.3%), patient's wish in one case (1.1%) and PSA progression in another case (1.1%). From the 17 cases (18.9%) transitioned to observation, there are still 11 patients in follow-up.</p><p id="par0085" class="elsevierStylePara elsevierViewall">There was a total of 21 (23.3%) patients undergoing active treatment: 20 received RT and one underwent radical prostatectomy.</p><p id="par0090" class="elsevierStylePara elsevierViewall">From those patients who underwent treatment with curative intent, 52.4% (11/21) were in good health condition at baseline (Charlson<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>2). Regarding the patients who transitioned to observation, this data was only identified in 35.3% (6/17). Those patients who received treatment with curative intent maintained stable Charlson index scores since their entry into the AS program until the moment when the choice of treatment administration was taken. However, a statistically significant comorbidity reduction was observed (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) from entry to exit from the AS program in those patients subjected to observation.</p><p id="par0095" class="elsevierStylePara elsevierViewall">From the group of patients who received RT, 6 (33%) presented complications, the most frequent were hematuria and rectal bleeding. One of these cases was classified as serious (Clavien <span class="elsevierStyleSmallCaps">III</span>), and the rest as mild (Clavien <span class="elsevierStyleSmallCaps">I–II</span>).</p><p id="par0100" class="elsevierStylePara elsevierViewall">Two patients (from the total study population) were treated with hormone therapy. One progressed to metastatic disease 9 years after diagnosis, with subsequent resistance to castration that was treated with new antiandrogens. A second patient started hormone therapy due to a group 4 Gleason (ISUP) result on the last AS biopsy. Until today, no patient treated with curative intent or under observation has had recurrence or progression. The median (interquartile range) follow-up until this year is 13.9 (51.6–6.1) and 18.6 (62.3–10.3) months, respectively.</p><p id="par0105" class="elsevierStylePara elsevierViewall">There was a total of 5 (5.5%) deaths. The patient with metastasis was the only cancer-related death. There were 2 documented non-cancer-related deaths in the observation group.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Several series regarding AS, including ours, confirm that there is a very low rate of cancer-specific progression and mortality in carefully selected patients with low risk disease. Likewise, the ratio of patients requiring deferred radical intervention is low. In the series reported by Klotz et al., they mention that the number of patients treated, those with progression of the disease, and the cancer-specific death cases are 27, 1.3 and 1.5%, respectively.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> In our published series, the proportion of patients requiring active treatment was lower (15.9%) and there were no patients presenting these other 2 events.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> This is probably due to the difference in the median follow-up between both series: 6.2 and 3.2 years, respectively.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The choice of treatment administration in patients with PC is based on the characteristics of the disease and of the patients, mainly their comorbidity and age. AS programs are based on the hypothesis that it is an alternative option to treatments with curative intent in indolent diseases at diagnosis, aiming to delay treatment until it is “oncologically required” (increased survival) or clinically beneficial (reduced symptoms), thus minimizing the morbidity caused by these treatments. However, AS series are growing over time, expanding their selection criteria and increasing the age of the patients included. Regarding these (elderly) patients included in AS programs, it is essential to find their best follow-up option and to know the impact of the application of a treatment with curative intent after the progression of the disease in terms of survival.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Since their advanced age ruled out surgical treatment in most cases, the patients who required active treatment in our series were mostly treated with RT. However, it should be considered that, although RT achieves a high cure rate,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> the toxicity described by this treatment is not negligible. As Peeters et al. describe in their series, the toxicity rate of grades 2 and 3 is 47 and 13%, respectively.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In our long series, those patients referred to the observation program have a great comorbidity burden that justifies avoiding any type of active treatment. As time goes by, patients included in AS are modifying their baseline condition, determined in our case by the Charlson index.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> In addition, we found a higher percentage of high comorbidity (Charlson<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>2) in those patients under observation compared to those receiving active treatment: 64.7% and 47.6%, respectively, without reaching statistically significant differences (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.34), probably due to the sample size.</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is worth mentioning that our series included some patients who did not strictly meet the very low risk PC-criteria. These patients were carefully selected, with a low life expectancy estimated at entry into the AS program, and with similar risk of progression to the group with very low risk, as has also been shown by other studies.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">We objectify that there have not been any cancer-related deaths in patients under observation, nor among those undergoing curative treatment. The only cancer-related death occurred in a patient who was still in AS at the time of metastatic progression.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The aging of the population is evident. The mean survival in the 2000–2005 period was approximately 65 years. It will increase to 74 years for the period 2045–2050. It must be highlighted that this difference will be even more noticeable regarding developed countries. The average life expectancy at birth was 76 years in the five-year period 2000–2005 and may increase to 81 by the middle of this century. In fact, the percentage of people over 60 years will increase at the expense of the population over 70 (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Therefore, the transition to observation continues being a challenge in routine clinical practice. Life expectancy is constantly increasing due to the new means available, and a cut-off point cannot be established for all patients. This decision should be taken individually, according to several clinical and pathological criteria, among which age and comorbidities are crucial in cases with very low or low-risk tumors.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The ideal management for the elderly population included in this type of surveillance protocols has not been established yet. On the one hand, it is necessary to determine the criteria for the transition from a AS program to an observation program. On the other hand, it is essential to know the results of the treatment with curative intent in this elderly population submitted to AS, when it becomes oncologically necessary.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Regarding the limitations of our study, we would like to emphasize on the descriptive retrospective nature of this study, which means that compliance with a rigorous and totally homogenous follow-up protocol cannot be ensured. Despite this, the usual pre-established guidelines for follow-up have been met in all patients. Another limitation is the 75-age cut-off point to determine a more limited life expectancy. It is becoming increasingly difficult to establish action guidelines based on the age criterion nowadays. In our case, we have tried to define this issue by including the Charlson index. In this sense, an algorithm to categorize patients according to their life expectancy, based on other predictive factors, would be useful. Finally, the scarce studies that address the transition of the elderly population in AS groups to an observation program hinders the possibility of a comparative discussion on clinical outcomes, especially regarding economic costs, greatly irregular from one medical care area to another.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">The transition of elderly prostate cancer patients from a AS program to observation, as well as the decision to carry out a treatment with curative intent, is controversial. The authors declare that they have no conflicts of interest.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1237821" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1148999" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1237822" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1149000" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objectives" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Material and method" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Follow-up protocol" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-01" "fechaAceptado" => "2018-10-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1148999" "palabras" => array:3 [ 0 => "Prostate cancer" 1 => "Active surveillance" 2 => "Observation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1149000" "palabras" => array:3 [ 0 => "Cáncer de próstata" 1 => "Vigilancia activa" 2 => "Observación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The world population is aging, and life expectancy is increasing. This situation will have a great impact on the management of patients with prostate cancer, especially in those of low risk, susceptible to a conservative management under active surveillance (AS). Regarding these patients’ profile, it is necessary to answer the following questions: ¿for how long to continue with the AS scheme?, ¿which tests will be required?, ¿is it possible to carry out a transition to observation with oncological safety? The objective of this work is to analyze those patients with prostatic cancer who have been in AS with 75 years of age or more and assess the safety of the observation in an AS series with a long follow-up.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We analyzed our prospective cohort of AS patients between the years 1999 and 2018, including those who had been in follow-up with 75 years or more. They were offered treatment with curative intent when there were progression criteria and transition to observation under the urologist's decision. Some intermediate risk patients were included in the analysis. Comorbidity changes were analyzed with the Charlson comorbidity index at entry and exit of AS. The progression and mortality of the patients were studied according to the management they received.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">From 347 AS patients, 90 patients fulfilled the afore mentioned criteria and 15 (16.7%) were intermediate risk. The median follow-up was 6.4 years and 73 (81.1%) had low comorbidity (Charlson<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>2). There were 40 (44.4%) patients who left AS, 17 (18.9%) of them went to observation and the rest, 21 (23.3%), received curative treatment. There was a significant difference in comorbidity, measured by the Charlson index, at entry and exit of AS (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) among patients receiving active treatment and the ones submitted to observation. No case of cancer-specific death or progression was observed in the observation group.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The transition from an active surveillance management to observation of prostate cancer elderly patients, as well as the decision to carry out a treatment with curative intent, seems controversial. In our series, this transition in patients older than 75 years does not increase the oncological risk.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La población mundial va envejeciendo y la esperanza de vida va siendo cada vez mayor; esta situación va a conllevar un gran impacto en el manejo de los pacientes con cáncer de próstata, sobre todo en aquellos de bajo riesgo susceptibles de un manejo conservador mediante la vigilancia activa (VA). En estos pacientes es necesario responder a las preguntas de hasta cuándo se ha de continuar con el esquema de VA, con qué pruebas y si es posible realizar una transición a observación con seguridad oncológica. El objetivo de este trabajo es analizar aquellos pacientes con cáncer de próstata que han estado en VA con 75 años o más y valorar la seguridad de la observación en una serie de VA con un largo seguimiento.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizó nuestra cohorte prospectiva de pacientes en VA entre los años 1999 y 2018, seleccionando aquellos que hubieran estado bajo seguimiento con 75 años o más. Se ofreció tratamiento con intención curativa cuando existían criterios de progresión y paso a observación a criterio del urólogo. Se incluyeron algunos pacientes de riesgo intermedio en el análisis. Los cambios de comorbilidad se analizaron teniendo en cuenta el Charlson a la entrada y salida de VA. Se estudió la progresión y la mortalidad en los pacientes según el manejo por el que se hubiera optado.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De un total de 347 pacientes en VA, 90 cumplían los criterios mencionados anteriormente, de los cuales 15 (16,7%) eran de riesgo intermedio. La mediana de seguimiento era de 6,4 años y 73 (81,1%) tenían baja comorbilidad (Charlson<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>2). Hubo 40 (44,4%) pacientes que salieron de VA, de los cuales 17 (18,9%) pasaron a observación; del resto, 21 (23,3%) recibieron tratamiento curativo. Se observó una diferencia significativa en el cambio de comorbilidad, medida por el índice de Charlson, a la entrada y salida de VA (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05) entre los pacientes sometidos a tratamiento activo y los sometidos a observación. No se observó ningún caso de muerte dependiente del cáncer ni progresión en el grupo de observación.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La transición desde un programa de VA a observación del cáncer de próstata en pacientes añosos, así como la decisión de llevar a cabo un tratamiento con intención curativa, resulta controvertida. En nuestra serie esta transición en pacientes mayores de 75 años no aumenta el riesgo oncológico.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández-Conejo G, de la Peña E, Hernández V, Pérez-Fernández E, Llorente C. Transición de vigilancia activa a observación en pacientes mayores de 75 años con cáncer de próstata en una serie de largo seguimiento. Actas Urol Esp. 2019;43:378–383.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1628 "Ancho" => 2500 "Tamanyo" => 190186 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Population pyramid: 2000–2050.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1543 "Ancho" => 2500 "Tamanyo" => 145031 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Percentage of world population over 60 years old versus total population: 1950–2050.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Ferlay" 1 => "I. Soerjomataram" 2 => "R. Dikshit" 3 => "S. Eser" 4 => "C. Mathers" 5 => "M. Rebelo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ijc.29210" "Revista" => array:6 [ "tituloSerie" => "Int J Cancer" "fecha" => "2015" "volumen" => "136" "paginaInicial" => "E359" "paginaFinal" => "E386" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25220842" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0065" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Active surveillance for prostate cancer: a systematic review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.A. Dall’Era" 1 => "P.C. Albertsen" 2 => "C. Bangma" 3 => "P.R. Carroll" 4 => "H.B. Carter" 5 => "M.R. Cooperberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eururo.2012.05.072" "Revista" => array:6 [ "tituloSerie" => "Eur Urol" "fecha" => "2012" "volumen" => "62" "paginaInicial" => "976" "paginaFinal" => "983" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22698574" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0070" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Watchful waiting and active surveillance: the current position" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Adolfsson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1464-410X.2008.07585.x" "Revista" => array:6 [ "tituloSerie" => "BJU Int" "fecha" => "2008" "volumen" => "102" "paginaInicial" => "10" "paginaFinal" => "14" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18422774" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0075" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changes in Gleason score grading on serial follow-up biopsies in prostate cancer patients undergoing active surveillance" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Guijarro" 1 => "V. Hernández" 2 => "B. López" 3 => "C. Capitán" 4 => "E. Pérez-Fernández" 5 => "E. de la Peña" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2014.08.002" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2015" "volumen" => "39" "paginaInicial" => "139" "paginaFinal" => "143" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25305107" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0080" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A new method of classifying prognostic comorbidity in longitudinal studies: development and validation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.E. Charlson" 1 => "P. Pompei" 2 => "K.L. Ales" 3 => "C.R. MacKenzie" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0021-9681(87)90171-8" "Revista" => array:6 [ "tituloSerie" => "J Chronic Dis" "fecha" => "1987" "volumen" => "40" "paginaInicial" => "373" "paginaFinal" => "383" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3558716" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0085" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term follow-up of a large active surveillance cohort of patients with prostate cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Klotz" 1 => "D. Vesprini" 2 => "P. Sethukavalan" 3 => "V. Jethava" 4 => "L. Zhang" 5 => "S. Jain" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1200/JCO.2014.55.1192" "Revista" => array:6 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "272" "paginaFinal" => "277" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25512465" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0090" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Results of active surveillance in low and intermediate risk prostate cancer]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Llorente" 1 => "F.J. Diaz Goizueta" 2 => "V. Hernandez" 3 => "J.M. de la Morena" 4 => "E. de la Peña" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Esp Urol" "fecha" => "2014" "volumen" => "67" "paginaInicial" => "452" "paginaFinal" => "456" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24914844" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0095" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Randomized trial comparing conventional-dose with high-dose conformal radiation therapy in early-stage adenocarcinoma of the prostate: long-term results from proton radiation oncology group/american college of radiology 95-09" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.L. Zietman" 1 => "K. Bae" 2 => "J.D. Slater" 3 => "W.U. Shipley" 4 => "J.A. Efstathiou" 5 => "J.J. Coen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1200/JCO.2009.25.8475" "Revista" => array:7 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2010" "volumen" => "28" "paginaInicial" => "1106" "paginaFinal" => "1111" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20124169" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0165178115001559" "estado" => "S300" "issn" => "01651781" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0100" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute and late complications after radiotherapy for prostate cancer: Results of a multicenter randomized trial comparing 68<span class="elsevierStyleHsp" style=""></span>Gy to 78<span class="elsevierStyleHsp" style=""></span>Gy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.T. Peeters" 1 => "W.D. Heemsbergen" 2 => "W.L. van Putten" 3 => "A. Slot" 4 => "H. Tabak" 5 => "J.W. Mens" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijrobp.2004.07.715" "Revista" => array:6 [ "tituloSerie" => "Int J Radiat Oncol Biol Phys" "fecha" => "2005" "volumen" => "61" "paginaInicial" => "1019" "paginaFinal" => "1034" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15752881" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0105" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "3<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6? Implications of the stratification of localised Gleason 7 prostate cancer by number and percentage of positive biopsy cores in selecting patients for active surveillance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.L. Ruiz-Cerdá" 1 => "L. Lorenzo Soriano" 2 => "D. Ramos-Soler" 3 => "L. Marzullo-Zucchet" 4 => "A. Loras Monfort" 5 => "F. Boronat Tormo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acuro.2017.07.006" "Revista" => array:6 [ "tituloSerie" => "Actas Urol Esp" "fecha" => "2018" "volumen" => "42" "paginaInicial" => "103" "paginaFinal" => "113" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28919101" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0110" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "United Nations. Department of International Economic and Social Affairs. World population prospects: the 2002 revision, online demographic profiles. Available from: <a target="_blank" href="https://population.un.org/wpp/Graphs/DemographicProfiles">https://population.un.org/wpp/Graphs/DemographicProfiles</a> [accessed Feb 2018]." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000004300000007/v1_201909021029/S2173578619300800/v1_201909021029/en/main.assets" "Apartado" => array:4 [ "identificador" => "6274" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000004300000007/v1_201909021029/S2173578619300800/v1_201909021029/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578619300800?idApp=UINPBA00004N" ]
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