Active Surveillance for Low‐Risk Prostate Cancer

Abstract

Active surveillance for localized prostate cancer entails initial expectant management rather than immediate therapy, with "curative-intent" treatment deferred until there is evidence that the patient is at increased risk for disease progression. This is a response to the clearly documented risks of over diagnosis and overtreatment of low-risk prostate cancer, which in most cases poses little or no threat to the patient. It is based upon the prolonged natural history of prostate cancer and is an attempt to balance the risks and side effects of overtreatment against the possibility of disease progression and a lost opportunity for cure. Low-risk prostate cancer is more accurately viewed as one of multiple risk factors for the presence of higher grade prostate cancer. Like atypical small acinar proliferation, (ASAP), it may be managed with close follow up but without radical intervention, unless there is clear evidence of more aggressive disease.

How can we expand active surveillance criteria in patients with low‐ and intermediate‐risk prostate cancer without increasing the risk of misclassification? Development of a novel risk calculator

“…Active surveillance (AS) represents an increasingly used option that aims to delay or avoid active treatment in selected patients with localised prostate cancer [1][2][3][4]. The oncological safety of this approach strongly depends on the adoption of strict selection criteria to identify eligible patients [5]. Although pathological findings at radical prostatectomy (RP) represent surrogate endpoints when developing selection approaches for AS candidates, several criteria that would allow for the reliable identification of insignificant prostate cancer that would pose little threat to patients, even if left untreated, have been proposed [3,6].…”

Patients' perceptions of mortality risk for localized prostate cancer vary markedly depending on their treatment strategy

“…In summary, the cancer-specific mortality is probably 3% or less after 10-15 years, if AS is the primary choice. 6 However, there are four main reasons to assume that patients' risk estimates will be biased. 7 (i) Because RP is still framed as the "default" 8 in clinical practice, it is likely that patients estimate the cancerspecific mortality risk for AS significantly higher than that for RP.…”

A contemporary analysis of disease upstaging of Gleason 3 + 3 prostate cancer patients after robot‐assisted laparoscopic prostatectomy

“…demonstrated that the mortality rate of those managed with AS is consistent with that of patients who had an initial definitive intervention over a 15‐year period. 11 , 12 , 13 As a result, there has been a greater focus on identifying and incorporating reliable prognostic indicators in patients diagnosed with low‐grade disease.…”