Active surveillance or active treatment in localized prostate cancer?

Abstract

Background: At present, one in six men over age 50 carries the diagnosis of prostate cancer, but only one in 33 will die of the disease. In view of these facts, conservative strategies such as active surveillance (AS) are important in the management of prostate cancer.

Methods: To obtain information on active surveillance, the Medline database was searched from January 2002 to April 2008 for the terms "prostate cancer" OR "prostatic neoplasms," AND "active surveillance" OR "expectant management". In addition a manual search was performed in the reference lists of relevant publications on the treatment of prostate cancer and on active surveillance.

Results: 88 relevant publications about active surveillance were found. The studies varied in methodological quality but consistently showed low rates of tumor progression and high rates of tumor-specific survival with active surveillance (99% to 100%). All 7 guidelines on the treatment of prostate cancer that have been published since 2006 list active surveillance in their recommendations as a therapeutic option for prostate cancer if there is a low risk of progression. In fact, the National Institute of Clinical Excellence (U.K.) recommends the active surveillance exclusively as the treatment strategy for such cases.

Conclusions: The guideline recommendations reflect a changed attitude toward the treatment of prostate cancer in the light of the early detection of these tumors and the data now available regarding active surveillance. A corresponding change in actual medical practice would be desirable. The treatment of prostate cancer should always be adapted to the individual needs of the patient, and risky treatments should only be used when absolutely necessary.

Keywords: PSA test; prostate cancer; prostatectomy; surveillance; treatment.

Figure 1

Kattan nomogram to predict indolent prostate cancer. The values in the top line are assigned to 7 tumor criteria, and the totals are entered on the penultimate line. The ultrasound volume is recorded in mL. The probability of an indolent cancer can then be read along the bottom line (23).