Risk-Based Selection for Active Surveillance

Abstract

Active surveillance (AS) is an increasingly important treatment modality aiming to reduce the overtreatment of patients with prostate cancer (PCa) who have a low risk of disease progression. Selecting patients for AS is complex, as is evident from the differences in guidelines with respect to combinations of clinical stage, biopsy outcomes, and PSA values.

The principle of a risk-based patient selection for AS is to indicate which patients have a low risk of PCa progression, such that active treatment with its possible complications and side effects can safely be postponed or avoided. These men need to be distinct from two other groups, namely, those with an underlying aggressive form of PCa where delaying treatment likely would be harmful and those with a very low lifetime risk of progression, where watchful waiting – a palliative strategy – would be optimal.

In this chapter, we demonstrate qualitative considerations in patient selection for AS and which endpoints should be used and provide recent literature comparing monitoring strategies with alternative treatment options. Secondly we review the eligibility criteria of several current guidelines and their empirical basis in underlying study cohorts. We then consider the suitability of existing prediction models for clinically insignificant PCa to assist in the selection for AS. Finally, we describe future developments such as the inclusion of promising new biomarkers, MRI, and specific pathologic findings to further improve risk-based patient selection for AS.