Active surveillance of prostate cancer

Active surveillance should not be confused with watchful waiting, another observational strategy for men that would not be candidates for curative therapy (surgery, radiation) because of a limited life expectancy.

[1] These included: The consensus statement highlighted the need for well-designed studies to address these questions as an important health research priority.

For these men, surveillance is thought to offer a more targeted approach to management; avoiding unnecessary treatment and its risk of associated side effects, while allowing for curative intervention for those that experience disease progression on observation.

[2] Further, because prostate cancer progresses slowly and is found most often in older men with competing risks of mortality, the extent to which these changes in natural history have resulted in benefit and harm are also debatable.

[7][8] The control arm (untreated) of randomized trials comparing surgery to watchful waiting represents an opportunity for evaluating the natural history of prostate cancer.

At 15 years after treatment (radiotherapy or surgery) of localized prostate cancer diagnosed in 1994–1995, declines in urinary, sexual, and bowel function were common.

Over treatment exacts a cost to the health care system and potential harm to a patient (decrease in quality of life), with no benefit.

A disturbing trend has been noted in men with newly diagnosed prostate cancer treated with robotic surgery and newer forms of radiotherapy (IMRT).

[9] After 15 years of follow-up, men that underwent surgical treatment had significantly lower rates of distant metastatic disease and death from prostate cancer.

[10] At 12 years, a subset of men with a PSA above 10 ng/ml and those with intermediate to high risk disease had a reduction in prostate cancer death with surgery as compared to watchful waiting.

[10] The findings from the SPGS-4 and PIVOT should inform practice for the older man with low risk disease, especially those with associated comorbidities unlikely to benefit from curative intervention.

For these men, no treatment may be the most rational initial management considering that harm (quality of life decrement) is likely to outweigh any benefit (prostate cancer mortality reduction).

[28][29][30][31] In terms of tumor metrics, natural history studies clearly demonstrate that Gleason score is a powerful predictor of the risk of disease progression and dissemination.

[32] In addition, the supplemental risk factor information provided by both stage and PSA at diagnosis should be included in making an active surveillance decision (see table above).

[44][45][46][47] Together with serum and urine biomarkers, this new paradigm may enhance our current stratification systems that rely to a great extent on light microscopic grading.

These include the Active Surveillance Program at the James Buchanan Brady Urological Institute of the Johns Hopkins Medical Institutions, the University of Toronto, and UCSF, all of which started in the early 1990s; the multi-institutional,[48] University of Miami, Prostate Cancer Research International Active Surveillance (PRIAS), Royal Marsden, Memorial Sloan Kettering.