When is Active Surveillance the Appropriate Treatment for Prostate Cancer?

Background: The incidence of prostate cancer has increased dramatically worldwide during the past few decades in part because of increased testing for prostate specific antigen (PSA). The aggressive use of this screening tool has resulted in the identification of many localized prostate cancers a majority of which are relatively low volume, low grade tumors. Older autopsy studies have documented that incidental prostate cancer is quite common especially in older men. The finasteride chemoprevention trial confirmed these findings. Many prostate cancers are not destined to progress to clinically significant tumors. Several case series have documented the natural history of clinically detected prostate cancer. The progression of disease identified by PSA testing is less certain. These studies uniformly show that many men with low grade tumors can survive for over two decades in the absence of treatment. Furthermore, randomized clinical trials have shown only a modest ten year survival advantage for those men undergoing either surgery or radiation.

Results: As a consequence, men with low risk of disease progression may wish to consider active surveillance as a treatment option. To date, several case series have documented that men following an active surveillance protocol that includes regular PSA testing and periodic re-biopsy have an excellent outcome. The majority of these men have not demonstrated evidence of progression during the first decade of follow-up and among those that have the majority have undergone either surgery or radiation without compromise of their long-term outcome. Unfortunately, until better biomarkers become available, the outcome of any individual patient defies accurate prediction.

Conclusion: Men with newly diagnosed prostate cancer must weigh the risk of disease progression against the potential efficacy and safety of treatment when making a decision whether to consider active surveillance as an appropriate treatment.