Skip to main content
SpringerLink
Log in

Active surveillance versus radical treatment for favorable-risk localized prostate cancer

  • Published:
Current Treatment Options in Oncology Aims and scope Submit manuscript

Opinion statement

Widespread prostate-specific antigen (PSA) screening in North America has resulted in a profound stage migration and a marked increase in incidence. One in six men is now diagnosed, many with small-volume, low-grade cancer. This incidence is dramatically higher than the 3% lifetime risk of prostate cancer death that characterized the prescreening era. This article summarizes the case for active surveillance for “favorable-risk” prostate cancer with selective delayed intervention for rapid biochemical progression, assessed by increasing PSA levels, or grade progression. The results of a large phase II trial using this approach are reviewed. To date, this study has shown that virtually all men with favorable-risk prostate cancer managed in this fashion will die of unrelated causes. Based on the Swedish randomized trial of radical prostatectomy versus watchful waiting, the Connecticut observation series, and the Toronto active surveillance experience, a number needed to treat analysis of the benefit of radical treatment of all newly diagnosed favorable-risk prostate cancer patients, compared with a strategy of active surveillance with selective delayed intervention, is presented. This suggests that approximately 73 patients will require radical treatment for each prostate cancer death averted. This translates into a 3- to 4-week survival benefit, unadjusted for quality of life. This figure is confirmed based on an analysis of the 2004 D'Amico et al. PSA velocity data in favorable-risk disease. The approach of active surveillance with selective delayed intervention based on PSA doubling time and repeat biopsy represents a practical compromise between radical therapy for all patients (which results in overtreatment for patients with indolent disease) and watchful waiting with palliative therapy only (which results in undertreatment for those with aggressive disease).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Sakr WA, Haas GP, Cassin BF, et al.: The frequency of carcinoma and intraepithelial neoplasia of the prostate in young male patients. J Urol 1993, 150:379–385. This study demonstrated the high prevalence of histologic prostate cancer in men in their 20s and 30s dying of unrelated causes, mostly trauma, and suggests that the lead time from inception of disease to clinical diagnosis is approximately 30 years.

    PubMed  CAS  Google Scholar 

  2. Boring CC, Squires TS, Tong T: Cancer statistics, 1993. CA Cancer J Clin 1993, 43:7–26.

    Article  PubMed  CAS  Google Scholar 

  3. Jemal A, Tiwari RC, Murray T, et al.: Cancer statistics, 2004. CA Cancer J Clin 2004, 54:8–29.

    Article  PubMed  Google Scholar 

  4. Welch HG, Schwartz LM, Woloshin S: Prostate-specific antigen levels in the United States: implications of various definitions for abnormal. J Natl Cancer Inst 2005, 97:1132–1137.

    Article  PubMed  Google Scholar 

  5. Thompson IM, Goodman PJ, Tangen CM, et al.: The influence of finasteride on the development of prostate cancer. N Engl J Med 2003, 349:215–224 This landmark trial was the first to subject a large cohort of men with a normal PSA to prostate biopsy; it showed a 25% positive biopsy rate in the placebo arm, confirming the serious risks of overdiagnosis of clinically insignificant disease. It also showed a 25% reduction in the risk of diagnosing prostate cancer in men treated with finasteride for 7 years.

    Article  PubMed  CAS  Google Scholar 

  6. McGregor M, Hanley JA, Boivin JF, et al.: Screening for prostate cancer: estimating the magnitude of overdetection. CMAJ 1998, 159:1368.

    PubMed  CAS  Google Scholar 

  7. Etzioni R, Penson DF, Legler JM, et al.: Overdiagnosis due to prostate-specific antigen screening: lessons from U.S. prostate cancer incidence trends. J Natl Cancer Inst 2002, 94:981–990.

    PubMed  Google Scholar 

  8. Pound CR, Partin AW, Eisenberger MA, et al.: Natural history of progression after PSA elevation following radical prostatectomy. JAMA 1999, 281:1591–1597. This important study of 2000 radical prostatectomies at Johns Hopkins University reported that the median time from surgery to prostate cancer death was 16 years in patients failing radical prostatectomy.

    Article  PubMed  CAS  Google Scholar 

  9. Tornblom M: Lead time associated with screening for prostate cancer. Int J Cancer 2004, 108:122–129.

    Article  PubMed  CAS  Google Scholar 

  10. Albertsen PC, Hanley JA, Fine J: 20-Year outcomes following conservative management of clinically localized prostate cancer. JAMA 2005, 293:2095–2101. This population-based study of watchful waiting in Connecticut showed that men with Gleason 6 or less prostate cancer had a risk of prostate cancer mortality at 20 years of between 15% and 23% without treatment. For most of these men, the risk of a non-prostate cancer death was much higher.

    Article  PubMed  CAS  Google Scholar 

  11. Stamey TA, Freiha FS, McNeal JE, et al.: Localized prostate cancer. Relationship of tumor volume to clinical significance for treatment of prostate cancer. Cancer 1993, 71:933–938.

    Article  PubMed  CAS  Google Scholar 

  12. Epstein JI, Walsh PC, Carmichael M, et al.: Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA 1994, 271:368–374.

    Article  PubMed  CAS  Google Scholar 

  13. Epstein JI, Pizov G, Walsh PC: Correlation of pathologic findings with progression after radical retropubic prostatectomy. Cancer 1993, 71:3582–3593.

    Article  PubMed  CAS  Google Scholar 

  14. Epstein JI, Carmichael M, Partin AW, et al.: Is tumor volume an independent predictor of progression following radical prostatectomy? A multivariate analysis of 185 clinical stage B adenocarcinomas of the prostate with 5 years of followup. J Urol 1993, 149:1478–1481.

    PubMed  CAS  Google Scholar 

  15. Epstein JI, Chan DW, Sokoll LJ, et al.: Nonpalpable stage T1c prostate cancer: prediction of insignificant disease using free/total prostate specific antigen levels and needle biopsy findings. J Urol 1998, 160:2407–2411.

    Article  PubMed  CAS  Google Scholar 

  16. Goto Y, Ohori M, Arakawa A, et al.: Distinguishing clinically important from unimportant prostate cancers before treatment: value of systematic biopsies. J Urol 1996, 156:1059–1063.

    Article  PubMed  CAS  Google Scholar 

  17. Kattan MW, Eastham JA, Wheeler TM, et al.: Counseling men with prostate cancer: a nomogram for predicting the presence of small, moderately differentiated, confined tumors. J Urol 2003, 170:1792–1797.

    Article  PubMed  Google Scholar 

  18. Augustin H, Hammerer PG, Graefen M, et al.: Insignificant prostate cancer in radical prostatectomy specimen: time trends and preoperative prediction. Eur Urol 2003, 43:455–460.

    Article  PubMed  Google Scholar 

  19. Noguchi M, Stamey TA, McNeal JE, et al.: Relationship between systematic biopsies and histological features of 222 radical prostatectomy specimens: lack of prediction of tumor significance for men with nonpalpable prostate cancer. J Urol 2001, 166:104–109; discussion 109-110.

    Article  PubMed  CAS  Google Scholar 

  20. Irwin MB, Trapasso JG: Identification of insignificant prostate cancers: analysis of preoperative parameters. Urology 1994, 44:862–867; discussion 867-868.

    Article  PubMed  CAS  Google Scholar 

  21. Cupp MR, Bostwick DG, Myers RP, Oesterling JE: The volume of prostate cancer in the biopsy specimen cannot reliably predict the quantity of cancer in the radical prostatectomy specimen on an individual basis. J Urol 1995, 153:1543–1548.

    Article  PubMed  CAS  Google Scholar 

  22. Anast JW, Andriole GL, Bismar TA, et al.: Relating biopsy and clinical variables to radical prostatectomy findings: can insignificant and advanced prostate cancer be predicted in a screening population. Urology 2004, 64:544–550.

    Article  PubMed  Google Scholar 

  23. Choo R, DeBoer G, Klotz L, et al.: PSA doubling time of prostate carcinoma managed with watchful observation alone. Int J Radiat Oncol Biol Phys 2001, 50:615–620.

    Article  PubMed  CAS  Google Scholar 

  24. Kakehi Y: PSA DT in Japanese active surveillance cohort (48 patients). Jpn J Clin Oncol 2003, 33:1–5.

    Article  PubMed  Google Scholar 

  25. Egawa S, Arai Y, Tobisu K, et al.: Use of pretreatment prostate-specific antigen doubling time to predict outcome after radical prostatectomy. Prostate Cancer Prostatic Dis 2000, 3:269–274.

    Article  PubMed  Google Scholar 

  26. McLaren DB, McKenzie M, Duncan G, et al.: Watchful waiting or watchful progression?: Prostate specific antigen doubling times and clinical behavior in patients with early untreated prostate carcinoma. Cancer 1998, 82:342–348.

    Article  PubMed  CAS  Google Scholar 

  27. D'Amico AV, Chen MH, Roehl KA, Catalona WJ: Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy. N Engl J Med 2004, 351:125–135. This study demonstrated that a PSA increase of more than 2 in the year before surgery identified 100% of men destined to die of prostate cancer (despite surgery) over the next 10 years.

    Article  PubMed  Google Scholar 

  28. Choo R, Klotz L, Danjoux C, et al.: Feasibility study: watchful waiting for localized low to intermediate grade prostate carcinoma with selective delayed intervention based on prostate specific antigen, histological and/or clinical progression. J Urol 2002, 167:1664–1669. This was the first report of a large cohort managed with the strategy of active surveillance with selective delayed intervention based on PSA kinetics and/or grade progression.

    Article  PubMed  Google Scholar 

  29. Klotz L: Active surveillance for prostate cancer: for whom. J Clin Oncol 2005, 23:8165–8169.

    Article  PubMed  Google Scholar 

  30. Klotz L: Active surveillance for good risk prostate cancer: rationale, method, and results. Can J Urol 2005, 12:21–24.

    PubMed  Google Scholar 

  31. Bill-Axelson A, Holmberg L, Ruutu M, et al.: Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005, 352:1977–1984. This critical study reports the updated results of a unique randomized trial of surgery versus watchful waiting, showing a 44% reduction in prostate cancer mortality at 10 years with radical prostatectomy.

    Article  PubMed  CAS  Google Scholar 

  32. Steineck G, Helgesen F, Adolfsson J, et al.: Quality of life after radical prostatectomy or watchful waiting. N Engl J Med 2002, 347:790–796. This is a companion study to the Scandinavian randomized study of watchful waiting versus prostatectomy, showing no difference in any domain related to psychological functioning, depression, or general sense of well being in patients managed expectantly. This suggests that the psychological stress of untreated and treated cancer is similar.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sunnybrook Health Sciences Center, University of Toronto, 2975 Bayview Avenue, #MG408, M4N 3M5, Toronto, Ontario, Canada

    Laurence Klotz MD, FRCS

Authors
  1. Laurence Klotz MD, FRCS
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Klotz, L. Active surveillance versus radical treatment for favorable-risk localized prostate cancer. Curr. Treat. Options in Oncol. 7, 355–362 (2006). https://doi.org/10.1007/s11864-006-0003-z

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11864-006-0003-z

Keywords

Search

Navigation