Expectant Management of Localized Prostate Cancer

Abstract

As a consequence of opportunistic PSA screening in the United, a man’s lifetime risk of being diagnosed with prostate cancer has increased from 6.7 to 18 %. While a 35 % relative decrease in prostate cancer mortality has accompanied this increased incidence, most estimates suggest that the vast majority of men diagnosed with prostate cancer did not benefit from early detection and may have been harmed, when one considers the negative effects of treatment on quality-of-life, in terms of urinary, bowel, and sexual function. Thus, expectant management has emerged as an alternative to radical therapy as a therapeutic strategy for low-risk prostate cancer. In appropriately selected patients, expectant management is associated with similar risks of prostate cancer-specific and all-cause mortality compared to radical therapy and the majority of men will avoid radical therapy, with the added benefits of improved urinary, bowel, and sexual function. Expectant management may take two forms: watchful waiting or active surveillance. Watchful waiting involves less intensive observation with the administration of androgen deprivation therapy at the time of symptomatic local or distant progression. Active surveillance involves close monitoring with frequent PSA checks, repeat biopsy, and intervention with curative intent is recommended when evidence of more important cancer is detected. Active surveillance has been the preferred approach by clinicians and patients who are concerned about the risks of disease progression with a watchful waiting strategy. In general, expectant management of any kind is relatively under-utilized in the United States due to concerns that clinical parameters will under-estimate the threat posed by a cancer to an individual’s longevity and quality of life. Recent randomized trials attesting to the safety of this approach and improvements in prognostication (with biomarkers and imaging) may improve the acceptance of this approach.