. Since 2003, millions have joined the men’s health movement, raising in excess of AUD $730 million and funding over 1,000 projects in 21 countries focusing on prostate cancer, testicular cancer, and suicide prevention. The Movember Foundation invests in initiatives that deepen the worldwide knowledge of prostate cancer through :
Trialing and implementing ways to improve the lives of men with prostate cancer from diagnosis through treatment, decision-making, active recovery, and well-being
Raising awareness and ensuring that prostate cancer is a public priority
Educating men on when and how to take action
Creating a new posttreatment care pathway that will help men living with prostate cancer to access care and support that enhance their quality of life
Investing in national prostate cancer clinical registries to provide population insights and an understanding of how to improve health outcomes for men throughout their prostate cancer journey
An Innovative Global Approach
The Movember Foundation believes that team-based research, performed across borders with a strong collaborative mind-set, avoiding duplication of work, can deliver innovation and knowledge sharing that leads to an acceleration of results that benefit men diagnosed and living with prostate cancer today. This has led to the realization of the Global Action Plan (GAP)
, a key initiative undertaken directly by the Movember Foundation. By bringing together over 350 international researchers, GAP facilitates a new and unprecedented level of global research collaboration, not previously seen within the prostate cancer community. There are seven GAP projects
focusing on the following areas: the Global Prostate Cancer Biomarker Initiative (GAP1), Imaging in Advanced Prostate Cancer (GAP2), Active Surveillance for Low-Risk Prostate Cancer (GAP3), Exercise and Metabolic Health in Advanced Prostate Cancer (GAP4), Testicular Cancer Translational Research Project (GAP5), Oligometastatic Prostate Cancer Initiative (GAP6), and Psychosocial and Peer Support for Testicular Cancer Project (GAP7) (Fig. 13.1
Global research collaboration
The Movember Foundation’s Global Action Plan Prostate Cancer Active Surveillance (GAP3) Initiative
The Movember Foundation has committed EUR €2.4 million to the Global Action Plan Prostate Cancer Active Surveillance (GAP3)
initiative to construct the largest centralized prostate cancer active surveillance database to date, comprising the majority of the world’s active surveillance patient data. This will help create a global consensus on the selection and monitoring of men with low-risk prostate cancer and will reduce the number switching to active therapy within 1 year after the start of the active surveillance protocol and has the potential to improve their quality of life [9
]. Overall milestones include worldwide consensus guidelines
on active surveillance and a worldwide web-based platform on active surveillance with information and guidelines on active surveillance as an acknowledged treatment option for prostate cancer.
Outcome from GAP3 for Patients and Clinicians
The analysis of the data collected will allow clinicians to better select men that are eligible for active surveillance [10
]. This will provide a safer option for men choosing to delay or avoid the potential side effects such as erectile dysfunction and incontinence that can be incurred by treatments such as surgery and radiation therapy. New guidelines will be created to allow clinicians to be able to more confidently identify men suitable for active surveillance and to also better determine when a man’s prostate cancer has progressed and therefore requires active treatment. This will provide reassurance
to men that they have made the most informed treatment decision for their type of disease [10
Who Is Involved?
Requirements for the participation in GAP3
include, among others, ethical approval for sharing digital patient data in a centralized global database and an active registry of active surveillance patients over the last 2 years or more, including at least 50 patients included annually. The global initiative has brought together a vast wealth of clinical and research experience in prostate cancer research and clinical practice with all partners from around the world benefiting from each other’s data, resources, and expertise to provide better outcomes for their patients. To date, GAP3 has united as many as 30 institutions, hospitals, and research centers from the USA, Canada, Australia, Singapore, Japan, Korea, the UK, Ireland, the Netherlands, France, Sweden, Finland, Switzerland, Italy, and Spain. This global network is still expanding since the initiative is open for other eligible centers to join as well. Figure 13.2
provides an overview of the institutions that are currently participating in GAP3.
Participating centers GAP3
In total, the original GAP3 project will take two and a half years to complete. In the first phase of the project, the global database will be created by combining existing active surveillance databases worldwide. The second phase will involve the development of a consensus guideline on active surveillance .
Phase 1: Design of the Global Database
Clinical Research Questions
What is a man’s risk on having event X (symptoms from metastases or prostate cancer death) when he starts following active surveillance? And what are the risks of side effects of a particular treatment (e.g., urinary dysfunction, bowel dysfunction, and erectile dysfunction) and loss of quality of life? The decision to pursue active surveillance is entirely the man’s, but it is the urologist’s responsibility
to make sure that the man fully understands all the benefits and risks of active surveillance, as well as the benefits and risks of other treatment options available [11
]. In order to assist both clinicians and patients in this critically important treatment-related decision-making process
, there are a number of questions which will be addressed:
What is the common definition of low-risk prostate cancer?
How can we establish the diagnosis of a low-risk prostate cancer?
What is the role of comorbidity/life expectancy?
What are the best monitoring tools and at which frequency should these be used?
What should trigger the switch from active surveillance toward watchful waiting?
What should define the switch from active surveillance toward active treatment?
How best to evaluate the efficacy of active surveillance?
These unresolved issues in active surveillance for prostate cancer require further study and are identified by the GAP3 clinical experts as the key questions of the global initiative .
Content GAP3 Database
What is the most informative data needed to answer these research questions? To achieve a consensus on the design and contents of the global active surveillance database, there was a need for a minimal definition of the GAP3 codebook. A consensus has been reached on the codebook of the GAP3 database among the clinical investigators. The codebook of the global database consists of four sections: inclusion, follow-up, before diagnosis, and end of active surveillance. At time of inclusion, the consortium is interested in recording host characteristics (e.g., age, BMI, race, ethnicity, marital status, educational level, life expectancy, comorbidities/overall health status, etc.) and tumor characteristics (e.g., clinical stage, PSA, biopsy Gleason score , PSA density, number of positive cores, maximum extent cancer per core, etc.). During follow-up, information is gathered on, e.g., PSA, PSA kinetics (PSADT, PSAV), T-stage by DRE, biopsy characteristics, and MRI findings. PSA before diagnosis is also registered. With regard to the end of active surveillance, an inventory is made of, e.g., the reasons for stopping active surveillance, type of metastasis, type of treatment, and cause of death. As a next step, an inventory on available data has been made, including potential markers, imaging, QOL data, and others.
Construction of the Central Database 
Based on the consensus contents of a global active surveillance database, Philips Research has constructed the GAP3 database. The IT infrastructure of the global database is based on the tranSMART prostate cancer instance of the TraIT IT infrastructure developed by Philips within the Dutch CTMM-TraIT (www.ctmm-trait.nl
) and CTMM-PCMM (www.ctmm.nl/en/projecten/kanker/pcmm?set_language=en
) projects. This infrastructure offers support for collecting and combining the various large, longitudinal datasets from the participating institutes (Fig. 13.3
). Transfer of these datasets takes place using the Secure Data Transfer (SDT) tool
provided by Philips. The clinical data has been gathered using a global data model, specifically designed to contain all the data items needed by the statisticians to answer the research questions defined by the principal investigators at the start of the project. During this process, several issues arose, such as low data quality and incompatibility of the local data models with the global data model. These issues were solved using quality check software and data mapping software that were developed in-house. The global dataset can be browsed through the web-based tranSMART platform, which is only accessible for a selected group of statisticians. tranSMART supports a number of statistical analyses, such as survival analysis, logistic regression, and correlation analysis, and can incorporate genomic data and imaging metadata as well. The tranSMART instance
is connected to RStudio [13
] to enable the statisticians to execute their own R [14
] scripts on the database, in a secure and reproducible manner.
The dataflow from the participating centers to the global database (*The overview of satellite centers is not exhaustive). DMZ demilitarized zone; LAS DBs local active surveillance databases; GAS DB global active surveillance database; ETL extract, transform, load
Other Activities in Phase 1
For quality control of the biopsy Gleason scores used for inclusion of patients for active surveillance and for decision-making during follow-up, a centralized pathology review of approximately 5% of the biopsies by virtual microscopy is currently conducted. It concerns a random selection of 5% of confirmatory biopsies of the active surveillance population of each of the participating centers included in GAP3. The hematoxylin-eosin-stained biopsy slides will be reviewed for Gleason score (primary and secondary GS) and the biopsy core length. In addition, data is collected on the maximum number of cores per cassette and the extent of carcinoma and the total core length. The results will be taken into account in the final statistical analysis. Expected improvements for patient care include the standardization of pathology grading of prostate cancers diagnosed on biopsies, the development of a quality parameter for prostate biopsy core length, and improved selection of men entering an active surveillance program.
Although described broadly as a management option for low-risk prostate cancer patients, there is a semantic heterogeneity in the literature and guidelines on active surveillance. For instance, the specific definitions of the terms active surveillance
and watchful waiting
) are inconsistent in the published literature and can elicit significant confusion. Further, various definitions of low-risk prostate cancer exist in these guidelines, as specified by different combinations of clinical criteria including clinical and pathological characteristics. Also, definitions of disease reclassification and progression differ among published guidelines, and multiple criteria for the initiation of curative treatment are proposed. Problems resulting from the use of ambiguous language include hindered clinical decision-making, particularly in multidisciplinary collaborations
, and limited opportunities for research [15
]. Further, it has raised a barrier that hampers exchange of knowledge within and between fundamental domains of research and research groups [16
]. An important step toward global consensus was therefore to define some sort of “new (but uniform) Active Surveillance language.” Consensus definitions were derived using a modified Delphi
method in which a panel of leading prostate cancer specialists in the field participated [17
Phase 2: The Development of a Consensus Guideline on Active Surveillance
Publication on Active Surveillance Guideline Consensus
The aim of the GAP3 initiative
is to create a global consensus on selecting and monitoring men with low-risk prostate cancer. As a first action, the project leaders started with the development of a guideline consensus on active surveillance based on a review of the current guidelines available around the world. Existing guidelines on active surveillance for clinically insignificant prostate cancer were systematically reviewed to provide a comprehensive view of the recommendations regarding patient selection, monitoring during active surveillance, and disease progression [18
Statistical Analysis of the Global Database
The consensus-based guidelines will be adapted based on the outcomes of the statistical analysis of the database. A brief description of the statistical analyses plan is provided below.
A conceptual framework
was developed to identify which patients are most suitable for active surveillance, relating life expectancy, risk, and treatment choice (Fig. 13.4
). If the patient’s life expectancy is relatively short, watchful waiting is the preferable option. If the patient’s life expectancy is relatively long, and the risk of adverse outcomes due to prostate cancer is relatively high, immediate treatment is preferred. Active surveillance is suitable for men with a relatively long life expectancy and low risk of adverse outcomes. The adverse side effects of treatment are avoided, and if disease progression
occurs, curative treatment may still be initiated. The key challenge here is to reasonably weigh the harms and benefits of all treatment options and identify the preferred treatment option for a patient.
Conceptual framework to identify patients suitable for active surveillance
Two possible end points are relevant for selecting patients that are fit for active surveillance, namely, reclassification (i.e., disease progression after 1 year) and progression (i.e., disease progression after 4 years). To identify patients who leave active surveillance within 1 year of commencing active surveillance, prediction models will be constructed to estimate the probability that a patient moves off the active surveillance protocol within 1 year. A similar approach will be followed when predicting the risk of leaving active surveillance after 4 years, using cox or logistic regression models. Performance measures used to assess the resulting models are discrimination, calibration, and clinical usefulness. Specific attention is needed for dealing with different patient cohorts. Final presentation of models will focus on risk stratification to categorize patients by likelihood of stopping active surveillance, and this will be compared to currently used stratification schemes.
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