Active Surveillance: Rationale, Patient Selection, Follow-up, and Outcomes

Introduction

The last century has witnessed a shift from invasive to minimally invasive surgery, and it has been proposed that the next century may bring the elimination of invasion altogether. For the management of localized prostate cancer, this is a very apt expectation. Active surveillance represents a major advance at the noninvasive end of the treatment spectrum and offers the critically important promise of reducing the number of patients required to be treated to reduce prostate cancer mortality effectively. This approach is reviewed in this chapter.

Background

Prostate-specific antigen (PSA) testing reduces prostate cancer mortality. However, in 2012 the US Preventive Services Task Force (USPSTF) published a Level D recommendation against PSA screening, based on concerns about overdiagnosis and overtreatment. Subsequently, a number of other national health policy organizations published recommendations that reflected ambivalence about the net value of screening. The result has been a steady decline in the rate of PSA testing and referral for biopsy over the last few years.

Histologic prostate cancer occurs normally with age, and the likelihood of harboring microfocal prostate cancer is approximately one’s age as a percentage; 50% of men over 50, for example. The effect of screening is to identify a large number of men with clinically insignificant prostate cancer who otherwise would not be diagnosed during their natural lifetime.

Prior to the USPSTF recommendation against PSA screening, almost all cases of localized prostate cancer were treated by either radical prostatectomy or high-dose radiation treatment. The task-force recommendation, bolstered by substantial evidence regarding the indolent nature of low-grade disease and the favorable outcome with conservative management, has resulted in an international consensus that these therapies represent an unacceptable level of overtreatment for low-risk prostate cancer, and the most widely accepted alternative to radical treatment is active surveillance.