Active surveillance of early prostate cancer: rationale, initial results and future developments
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Active surveillance in prostate cancer The spread of PSA in the screening of prostate cancer has almost doubled the incidence of this disease in the last twenty years. An improved understanding of the natural history of this cancer allows for risk stratification of the disease and to better predict insignificant prostate cancer. Active surveillance has recently been proposed as a new option to delay or avoid a radical treatment for patients with low-risk disease. The principle, results and future perspectives of this treatment modality are discussed in this review.
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To review the economics of managing low-risk prostate cancer with active surveillance compared with other standard therapies.The expenses of caring for men with prostate cancer vary depending on treatment modality chosen and appear to be escalating. Costs are generally lowest with traditional watchful waiting and highest with radiation therapy. Compared with immediate treatment, active surveillance can result in a net per-patient savings of $12194 at 5 years and $4329 at 10 years. Active surveillance demonstrates lower 5-year costs over other initial treatments as long as fewer than 70% exit active surveillance in any given year and at least 12% of men remain on active surveillance at year 5. Yearly surveillance biopsy reduces the average simulated cost savings at 10 years by $4951 per patient.Active surveillance represents a cost-effective strategy for managing low-risk prostate cancer, as the majority of men remain without additional treatment over time. Prostate biopsy is the highest expenditure associated with active surveillance, and increasing the frequency of prostate biopsy will reduce the cost-effectiveness of this approach.
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Abstract It is worth distinguishing between the two strategies of expectant management for prostate cancer. Watchful waiting entails administering non‐curative androgen deprivation therapy to patients on development of symptomatic progression, whereas active surveillance entails delivering curative treatment on signs of disease progression. The objectives of the two management strategies and the patients enrolled in either are different: (i) to review the role of active surveillance as a management strategy for patients with low‐risk prostate cancer; and (ii) review the benefits and pitfalls of active surveillance. We carried out a systematic review of active surveillance for prostate cancer in the literature using the National Center for Biotechnology Information's electronic database, PubMed. We carried out a search in English using the terms: active surveillance, prostate cancer, watchful waiting and conservative management. Selected studies were required to have a comprehensive description of the demographic and disease characteristics of the patients at the time of diagnosis, inclusion criteria for surveillance, and a protocol for the patients' follow up. Review articles were included, but not multiple papers from the same datasets. Active surveillance appears to reduce overtreatment in patients with low‐risk prostate cancer without compromising cancer‐specific survival at 10 years. Therefore, active surveillance is an option for select patients who want to avoid the side‐effects inherent to the different types of immediate treatment. However, inclusion criteria for active surveillance and the most appropriate method of monitoring patients on active surveillance have not yet been standardized.
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To give insight into recent literature (during the past 12-18 months) reporting on oncologic outcomes of men on active surveillance.From recent published trials comparing radical prostatectomy vs. watchful waiting, we learn that radical treatment only benefits a small proportion of men and that a substantial part of men is overtreated. Therefore, active surveillance should aim at postponing treatment for most, but still generate the same disease-specific mortality as radical prostatectomy by treating only those who benefit. In this review some recent published data on prostate cancer-specific mortality under active surveillance as well as intermediate outcomes are described.Prostate cancer-specific mortality under active surveillance is very low; however, longer follow-up is warranted. When deferred radical treatment and immediate radical treatment are compared, results seem to be quite similar, suggesting that postponing treatment does not affect the outcomes of men under active surveillance. Furthermore, in the majority of men active treatment could be avoided completely, without compromising oncologic outcome.
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