Active surveillance for prostate cancer: an underutilized opportunity for reducing harm

Abstract

The management of localized prostate cancer is controversial, and in the absence of comparative trials to inform best practice, choices are driven by personal beliefs with wide variation in practice patterns. Men with localized disease diagnosed today often undergo treatments that will not improve overall health outcomes, and active surveillance has emerged as one approach to reducing this overtreatment of prostate cancer. The selection of appropriate candidates for active surveillance should balance the risk of harm from prostate cancer without treatment, and a patient's personal preferences for living with a cancer and the potential side effects of curative treatments. Although limitations exist in assessing the potential for a given prostate cancer to cause harm, the most common metrics used today consider cancer stage, prostate biopsy features, and prostate-specific antigen level together with the risk of death from nonprostate causes based on age and overall state of health.

Figure 1.

Percent of men upgraded to Gleason score above 6 on surveillance biopsies after diagnosis. Surveillance biopsy (Bx) number shown on x-axis; numbers in parentheses represent absolute number of men at University of California San Francisco (UCSF) and Johns Hopkins (JHH), respectively, undergoing a biopsy. Ninety-six percent of men at UCSF and 100% of men at JHH had Gleason score 6 at initial diagnosis. Data from UCSF adapted from Porten et al. (46), and from JHH adapted from Tosoian et al. (42).