Current Treatment Options in Oncology

, Volume 14, Issue 1, pp 97–108 | Cite as

Active Surveillance for Prostate Cancer: Overview and Update

Genitourinary Cancer (R Pili, Section Editor)

Opinion statement

Low-risk prostate cancer: How I would treat it?

Overtreatment of many conditions diagnosed by screening has become increasingly recognized as a contemporary malady associated with modern medicine’s efforts at earlier detection. The diagnosis of low-grade prostate cancer clearly qualifies as an example of potential overdiagnosis and overtreatment. Active surveillance for low-risk prostate cancer is an attempt to reduce the overtreatment of the disease. The approach involves initial expectant management rather than immediate therapy. Curative treatment is deferred while the patient is monitored and offered for evidence of risk reclassification to a more aggressive form of the disease. The basis for this approach is substantial evidence confirming the long natural history of most prostate cancers. The objective is to balance the risks of overtreatment and associated adverse quality of life effects, against the risk of progression of disease and a missed opportunity for curative therapy. Low-risk prostate cancer is more accurately viewed as one of several risk factors for the patient harboring higher-grade disease, rather than a life-threatening condition. This approach is similar to that taken historically for so-called precancerous conditions, such as PIN or ASAP, where patients were managed with close follow-up but without radical intervention unless clear evidence of more aggressive disease is identified. Active surveillance is increasingly viewed as the management of choice for patients with very low-risk (low-grade, low-volume prostate cancer) and low-risk (low-grade but higher volume) disease.


Prostate cancer Active surveillance Conservative management Low risk cancer Risk reclassification 



prostate-specific antigen


European Randomized Trial of Screening for Prostate Cancer


Prostate Cancer Prevention Trial


magnetic resonance imaging



No potential conflicts of interest relevant to this article were reported.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60:277–300.PubMedCrossRefGoogle Scholar
  2. 2.•
    Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102:605–13. A beautiful summary of the issues in cancer overdiagnosis, with many compelling examples of sites other than prostate cancer.PubMedCrossRefGoogle Scholar
  3. 3.
    Wever EM, Draisma G, Heijnsdijk EAM, de Koning HJ. How does early detection by screening affect disease progression? Modeling estimated benefits in prostate cancer screening. Med Decis Making. 2011;31:550–8.PubMedCrossRefGoogle Scholar
  4. 4.
  5. 5.•
    Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725–32. The most mature, high-quality screening study in the literature shows a significant mortality reduction and a NNT of 12.PubMedCrossRefGoogle Scholar
  6. 6.•
    Crawford ED, Grubb R, Black A, Andriole GL, Chen M, Izmirlian G, et al. Comorbidity and mortality results from a randomized prostate cancer screening trial. J Clin Oncol. 2011;29:355–61. A reanalysis of the PLCO study showing a significant benefit in healthy men.PubMedCrossRefGoogle Scholar
  7. 7.
    Porten SP, Whitson JM, Cowan JE, Cooperberg MR, Shinohara K, Perez N, et al. Changes in prostate cancer grade on serial biopsy in men undergoing active surveillance. J Clin Oncol. 2011;29:2795–800.PubMedCrossRefGoogle Scholar
  8. 8.
    D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Schnall M, Tomaszewski JE, et al. A multivariate analysis of clinical and pathological factors that predict for prostate specific antigen failure after radical prostatectomy for prostate cancer. J Urol. 1995;154:131–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Epstein JI. Prognostic significance of tumor volume in radical prostatectomy and needle biopsy specimens. J Urol. 2011;186:790–7.PubMedCrossRefGoogle Scholar
  10. 10.••
    Stamey TA, Freiha FS, McNeal JE, Redwine EA, Whittemore AS, Schmid HP. Localized prostate cancer. Relationship of tumor volume to clinical significance for treatment of prostate cancer. Cancer. 1993;71:933–8. A historic paper that provided the basis for the widely utilized definition of clinically insignificant disease as Gleason pattern 3 or less, with 0.5 cc or less of cancer.PubMedCrossRefGoogle Scholar
  11. 11.•
    Wolters T, Roobol MJ, van Leeuwen PJ, van den Bergh RCN, Hoedemaeker RF, van Leenders GJLH, et al. A critical analysis of the tumor volume threshold for clinically insignificant prostate cancer using a data set of a randomized screening trial. J Urol. 2011;185:121–5. A redefinition of “clinically insignificant disease” based on ERSPC data. Should be read in comparison with reference 11, above.PubMedCrossRefGoogle Scholar
  12. 12.•
    Hanahan D, Weinberg RA. The hallmarks of cancer. Cell. 2000;100:57–70. A classic paper on the biologic features that characterize cancer.PubMedCrossRefGoogle Scholar
  13. 13.•
    Ganz PA, Barry JM, Burke W, et al. National Institutes of Health State-of-the-Science Conference: role of active surveillance in the management of men with localized prostate cancer. Ann Intern Med. 2012;156:591–95. Conclusions of the historic NIH Consensus Conference on active surveillance.PubMedGoogle Scholar
  14. 14.
    Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. 2009;302:1685–92.PubMedCrossRefGoogle Scholar
  15. 15.
    Klotz L. Cancer overdiagnosis and overtreatment. Curr Opin Urol. 2012;22:203–09.PubMedCrossRefGoogle Scholar
  16. 16.
    Nickel JC, Speakman M. Should we really consider Gleason 6 prostate cancer? BJU Int. 2012;109:645–46.PubMedCrossRefGoogle Scholar
  17. 17.
    Porten S, Carroll P. Changes in cancer volume in serial biopsies of men on active surveillance for early stage prostate cancer. J Urol. 2011;185(5):1825–9.CrossRefGoogle Scholar
  18. 18.
    Klotz L. Expectant management with selective delayed intervention for favorable risk prostate cancer. Urol Oncol. 2002;7(5):175.PubMedCrossRefGoogle Scholar
  19. 19.
    Patel MI, DeConcini DT, Lopez-Corona E, Ohori M, Wheeler T, Scardino PT. An analysis of men with clinically localized prostate cancer who deferred definitive therapy. J Urol. 2004;171(4):1520–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Hardie C, Parker C, Norman A, Eeles R, Horwich A, Huddart R, et al. Early outcomes of active surveillance for localized prostate cancer. BJU Int. 2005;95(7):956–60.PubMedCrossRefGoogle Scholar
  21. 21.
    Carter HB, Kettermann A, Warlick C, Metter EJ, Landis P, Walsh PC, et al. Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience. J Urol. 2007;178:2359–64. discussion 2364-5.PubMedCrossRefGoogle Scholar
  22. 22.
    Roemeling S, Roobol MJ, de Vries SH, Wolters T, Gosselaar C, van Leenders GJLH, et al. Active surveillance for prostate cancers detected in three subsequent rounds of a screening trial: characteristics, PSA doubling times, and outcome. Eur Urol. 2007;51:1244–50. discussion 1251.PubMedCrossRefGoogle Scholar
  23. 23.
    Soloway MS, Soloway CT, Eldefrawy A, Acosta K, Kava B, Manoharan M. Careful selection and close monitoring of low-risk prostate cancer patients on active surveillance minimizes the need for treatment. Eur Urol. 2010;58:831–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Kakehi Y, Kamoto T, Shiraishi T, Ogawa O, Suzukamo Y, Fukuhara S, et al. Prospective evaluation of selection criteria for active surveillance in Japanese patients with stage T1cN0M0 prostate cancer. Jpn J Clin Oncol. 2008;38(2):122–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Dall'Era MA, Konety BR, Cowan JE, Shinohara K, Stauf F, Cooperberg MR, et al. Active surveillance for the management of prostate cancer in a contemporary cohort. Cancer. 2008;112(12):2664–70.PubMedCrossRefGoogle Scholar
  26. 26.
    van den Bergh RCN, Roemeling S, Roobol MJ, Aus G, Hugosson J, Rannikko AS, et al. Outcomes of men with screen-detected prostate cancer eligible for active surveillance who were managed expectantly. Eur Urol. 2009;55:1–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Bill-Axelson A, Holmberg L, Ruutu M, Garmo H, Stark JR, Busch C, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364:1708–17.PubMedCrossRefGoogle Scholar
  28. 28.
    Klotz L, Thompson I. Early prostate cancer–treat or watch? N Engl J Med. 2011;365:569.PubMedCrossRefGoogle Scholar
  29. 29.••
    Klotz L, Zhang L, Lam A, Nam R, Mamedov A, Loblaw A. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol. 2010;28:126–31. Latest results of the largest, single-center, most mature, prospective cohort of active surveillance patients.PubMedCrossRefGoogle Scholar
  30. 30.
    Krakowsky Y, Loblaw A, Klotz L. Prostate cancer death of men treated with initial active surveillance: clinical and biochemical characteristics. J Urol. 2010;184:131–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Helpap B, Egevad L. Modified Gleason grading. An updated review. Histol Histopathol. 2009;24(5):661–6.PubMedGoogle Scholar
  32. 32.
    Choo R, Klotz L, Danjoux C, Morton GC, DeBoer G, Szumacher E, 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(4):1664–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Cooperberg MR, Cowan JE, Hilton JF, Reese AC, Zaid HB, Porten SP, et al. Outcomes of active surveillance for men with intermediate-risk prostate cancer. J Clin Oncol. 2011;29(2):228–34.PubMedCrossRefGoogle Scholar
  34. 34.
    Bul M, van den Bergh RC, Zhu X, Rannikko A, Vasarainen H, Bangma CH, Schröder FH, Roobol MJ: Outcomes of initially expectantly managed patients with low or intermediate risk screen-detected localized prostate cancer. BJU Int 2012 Aug 29Google Scholar
  35. 35.
    Ross AE, Loeb S, Landis P, Partin AW, Epstein JI, Kettermann A, et al. Prostate-specific antigen kinetics during follow-up are an unreliable trigger for intervention in a prostate cancer surveillance program. J Clin Oncol. 2010;28:2810–6.PubMedCrossRefGoogle Scholar
  36. 36.•
    Vickers AJ, Savage C, O'Brien MF, Lilja H. Systematic review of pretreatment prostate-specific antigen velocity and doubling time as predictors for prostate cancer. J Clin Oncol. 2009;27:398–403. A very negative systematic overview regarding the value of PSA kinetics in the prediction of aggressivity of localized prostate cancer.PubMedCrossRefGoogle Scholar
  37. 37.
    Loblaw A, Zhang L, Lam A, Nam R, Mamedov A, Vesprini D, et al. Comparing prostate specific antigen triggers for intervention in men with stable prostate cancer on active surveillance. J Urol. 2010;184:1942–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Villeirs GM, de Meerleer GO, de Visschere PJ, Fonteyne VH, Verbaeys AC, Oosterlinck W. Combined magnetic resonance imaging and spectroscopy in the assessment of high grade prostate carcinoma in patients with elevated PSA: a single-institution experience of 356 patients. Eur J Radiol. 2011;77:340–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Delongchamps NB, Beuvon F, Eiss D, Flam T, Muradyan N, Zerbib M, et al. Multiparametric MRI is helpful to predict tumor focality, stage, and size in patients diagnosed with unilateral low-risk prostate cancer. Prostate Cancer Prostatic Dis. 2011;14:232–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med. 2003;349:215–24.PubMedCrossRefGoogle Scholar
  41. 41.
    Andriole GL, Bostwick DG, Brawley OW, Gomella LG, Marberger M, Montorsi F, et al. Effect of dutasteride on the risk of prostate cancer. N Engl J Med. 2010;362:1192–202.PubMedCrossRefGoogle Scholar
  42. 42.•
    Fleshner NE, Lucia MS, Egerdie B, Aaron L, Eure G, Nandy I, et al. Dutasteride in localised prostate cancer management: the REDEEM randomised, double-blind, placebo-controlled trial. Lancet. 2012;379:1103–11. This randomized study demonstrates the value of five ARI in men on surveillance. More than a 40% reduction in “progression” was seen, with no increase in high grade cancer in the five ARI group.PubMedCrossRefGoogle Scholar
  43. 43.
    Johansson E, Steineck G, Holmberg L, Johansson J, Nyberg T, Ruutu M, et al. Long-term quality-of-life outcomes after radical prostatectomy or watchful waiting: the Scandinavian Prostate Cancer Group-4 randomised trial. Lancet Oncol. 2011;12:891–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Vasarainen H, Lokman U, Ruutu M, Taari K, Rannikko A. Prostate cancer active surveillance and health-related quality of life: results of the Finnish arm of the prospective trial. BJU Int. 2012;109:1614–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Kasperzyk JL, Shappley WV, Kenfield SA, Mucci LA, Kurth T, Ma J, et al. Watchful waiting and quality of life among prostate cancer survivors in the Physicians' Health Study. J Urol. 2011;186:1862–7.PubMedCrossRefGoogle Scholar
  46. 46.••
    Schröder FH, Hugosson J, Roobol MJ, Tammela TLJ, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320–8. The critically important ERSPC publication showing a 20% mortality reduction with screening.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada

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