Skip to main content

Advertisement

SpringerLink
Log in

Watchful waiting versus active surveillance: Appropriate patient selection

  • Published:
Current Urology Reports Aims and scope Submit manuscript

Abstract

The prostate-specific antigen (PSA) screening era has seen dramatic stage and age migration in patients with newly diagnosed prostate cancer. The average serum PSA level of newly diagnosed patients is about 6 ng/dL, and 60% of patients are diagnosed with clinical stage T1c disease. There is evidence that many low-grade and low-stage prostate cancers have a slow growth rate and protracted clinical course, with a very low threat of metastasis or death over a prolonged interval. Many men are also appropriately concerned about the impact of prostate cancer treatment on sexual and urinary function. Therefore, delaying therapy in favor of careful surveillance, with the expectation of delivering curative treatment upon evidence of progression, is an attractive concept. In this review, we discuss active surveillance, contrast it to watchful waiting, and define common inclusion criteria. We compare follow-up regimens and discuss indications and intervention outcomes after active surveillance. Finally, we support well-designed prospective clinical trials that evaluate active surveillance compared with immediate definitive treatment.

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. Albertsen PC, Hanley JA, Fine J: 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA 2005, 293:2095–2101.

    Article  PubMed  CAS  Google Scholar 

  2. Johansson JE, Andren O, Andersson SO, et al.: Natural history of early, localized prostate cancer. JAMA 2004, 291:2713–2719.

    Article  PubMed  CAS  Google Scholar 

  3. Yatani R, Chigusa I, Akazaki K, et al.: Geographic pathology of latent prostatic carcinoma. Int J Cancer 1982, 29:611–616.

    Article  PubMed  CAS  Google Scholar 

  4. Rullis I, Shaeffer JA, Lilien OM: Incidence of prostatic carcinoma in the elderly. Urology 1975, 6:295–297.

    Article  PubMed  CAS  Google Scholar 

  5. Cooperberg MR, Lubeck DP, Meng MV, et al.: The changing face of low-risk prostate cancer: trends in clinical presentation and primary management. J Clin Oncol 2004, 22:2141–2149.

    Article  PubMed  Google Scholar 

  6. Litwin MS, Gore JL, Kwan L, et al.: Quality of life after surgery, external beam irradiation, or brachytherapy for early-stage prostate cancer. Cancer 2007, 109:2239–2247.

    Article  PubMed  Google Scholar 

  7. Draisma G, Boer R, Otto SJ, et al.: Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer. J Natl Cancer Inst 2003, 95:868–878.

    Article  PubMed  Google Scholar 

  8. 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.

    Article  PubMed  CAS  Google Scholar 

  9. Wong YN, Mitra N, Hudes G, et al.: Survival associated with treatment vs observation of localized prostate cancer in elderly men. JAMA 2006, 296:2683–2693.

    Article  PubMed  CAS  Google Scholar 

  10. Tward JD, Lee CM, Pappas LM, et al.: Survival of men with clinically localized prostate cancer treated with prostatectomy, brachytherapy, or no definitive treatment: impact of age at diagnosis. Cancer 2006, 107:2392–2400.

    Article  PubMed  Google Scholar 

  11. Walz J, Gallina A, Perrotte P, et al.: Clinicians are poor raters of life-expectancy before radical prostatectomy or definitive radiotherapy for localized prostate cancer. BJU Int 2007, 100:1254–1258.

    Article  PubMed  Google Scholar 

  12. Social Security Online: Actuarial publications. Accessible at http://www.ssa.gov/OACT/pubs.html. Accessed February 2008.

  13. National Center for Health Statistics: Life tables. Accessible at http://www.cdc.gov/nchs/products/pubs/pubd/lftbls/lftbls.htm. Accessed February 2008.

  14. Walz J, Gallina A, Saad F, et al.: A nomogram predicting 10-year life expectancy in candidates for radical prostatectomy or radiotherapy for prostate cancer. J Clin Oncol 2007, 25:3576–3581.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  16. Greene KL, Elkin EP, Karapetian A, et al.: Prostate biopsy tumor extent but not location predicts recurrence after radical prostatectomy: results from CaPSURE. J Urol 2006, 175:125–129; discussion 129.

    Article  PubMed  Google Scholar 

  17. Roemeling S, Roobol MJ, Postma R, et al.: Management and survival of screen-detected prostate cancer patients who might have been suitable for active surveillance. Eur Urol 2006, 50:475–482.

    Article  PubMed  Google Scholar 

  18. Carter HB, Walsh PC, Landis P, Epstein JI: Expectant management of nonpalpable prostate cancer with curative intent: preliminary results. J Urol 2002, 167:1231–1234.

    Article  PubMed  Google Scholar 

  19. Venkitaraman R, Norman A, Woode-Amissah R, et al.: Prostate-specific antigen velocity in untreated, localized prostate cancer. BJU Int 2008, 101:161–164.

    PubMed  CAS  Google Scholar 

  20. Partin AW, Mangold LA, Lamm DM, et al.: Contemporary update of prostate cancer staging nomograms (Partin tables) for the new millennium. Urology 2001, 58:843–848.

    Article  PubMed  CAS  Google Scholar 

  21. D’Amico AV, Whittington R, Malkowicz SB, et al.: Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 1998, 280:969–974.

    Article  PubMed  CAS  Google Scholar 

  22. Kattan MW, Eastham JA, Stapleton AM, et al.: A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst 1998, 90:766–771.

    Article  PubMed  CAS  Google Scholar 

  23. Cooperberg MR, Pasta DJ, Elkin EP, et al.: The University of California, San Francisco Cancer of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. J Urol 2005, 173:1938–1942.

    Article  PubMed  Google Scholar 

  24. 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 

  25. Roemeling S, Roobol MJ, Kattan MW, et al.: Nomogram use for the prediction of indolent prostate cancer: impact on screen-detected populations. Cancer 2007, 110:2218–2221.

    Article  PubMed  Google Scholar 

  26. Steyerberg EW, Roobol MJ, Kattan MW, et al.: Prediction of indolent prostate cancer: validation and updating of a prognostic nomogram. J Urol 2007, 177:107–112; discussion 112.

    Article  PubMed  CAS  Google Scholar 

  27. Klotz L: Active surveillance with selective delayed intervention for favorable risk prostate cancer. Urol Oncol 2006, 24:46–50.

    PubMed  Google Scholar 

  28. Freedland SJ, Kane CJ, Amling CL, et al.: Upgrading and downgrading of prostate needle biopsy specimens: risk factors and clinical implications. Urology 2007, 69:495–499.

    Article  PubMed  Google Scholar 

  29. Emiliozzi P, Maymone S, Paterno A, et al.: Increased accuracy of biopsy Gleason score obtained by extended needle biopsy. J Urol 2004, 172:2224–2226.

    Article  PubMed  CAS  Google Scholar 

  30. Epstein JI, Walsh PC, Sauvageot J, Carter HB: Use of repeat sextant and transition zone biopsies for assessing extent of prostate cancer. J Urol 1997, 158:1886–1890.

    Article  PubMed  CAS  Google Scholar 

  31. Vashi AR, Wojno KJ, Gillespie B, Oesterling JE: A model for the number of cores per prostate biopsy based on patient age and prostate gland volume. J Urol 1998, 159:920–924.

    Article  PubMed  CAS  Google Scholar 

  32. Dall’Era MA, Kane CJ, Meng MV, et al.: Pathologic outcomes for men on active surveillance who undergo radical prostatectomy do not differ from men undergoing immediate treatment. J Urol 2007, 177:203.

    Article  Google Scholar 

  33. Wilt TJ, Brawer MK: The Prostate Cancer Intervention Versus Observation Trial (PIVOT). Oncology (Williston Park) 1997, 11:1133–1139; discussion 1139–1140, 1143.

    CAS  Google Scholar 

  34. Latini DM, Hart SL, Knight SJ, et al.: The relationship between anxiety and time to treatment for patients with prostate cancer on surveillance. J Urol 2007, 178:826–831; discussion 831–822.

    Article  PubMed  Google Scholar 

  35. Bailey DE, Mishel MH, Belyea M, et al.: Uncertainty intervention for watchful waiting in prostate cancer. Cancer Nurs 2004, 27:339–346.

    Article  PubMed  Google Scholar 

  36. Loblaw DA, Choo R, Zhang L, et al.: Updated follow-up of active surveillance with selected delayed intervention for localized prostate cancer. Presented at the 2nd Annual Multidisciplinary Prostate Cancer Symposium (abstract 37). San Francisco, CA; February 24–26, 2006.

  37. Kakehi Y, Kamoto T, Ogawa O, et al.: Prospective evaluation of a “watchful waiting” program using initial pathology criteria and PSA-doubling time monitoring for patients with stage T1c prostate cancer. J Clin Oncol 2006, 24:18S.

    Article  Google Scholar 

  38. Hardie C, Parker C, Norman A, et al.: Early outcomes of active surveillance for localized prostate cancer. BJU Int 2005, 95:956–960.

    Article  PubMed  Google Scholar 

  39. Carter HB, Kettermann A, Warlick C, et al.: Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience. J Urol 2007, 178:2359–2364; discussion 2364–2355.

    Article  PubMed  Google Scholar 

  40. Dall’Era MA, Kane CJ, Konety BR, et al.: Baseline characteristics and predictors of progression in an active surveillance cohort: the UCSF experience. J Urol 2007, 177:205.

    Google Scholar 

  41. Mohler JL, Williams BT, Freeman JA: Expectant management as an option for men with stage T1c prostate cancer: a preliminary study. World J Urol 1997, 15:364–368.

    Article  PubMed  CAS  Google Scholar 

  42. Soloway MS, Soloway CT, Williams S, et al.: Active surveillance; a reasonable management alternative for patients with prostate cancer: the Miami experience. BJU Int 2008, 101:165–169.

    PubMed  Google Scholar 

  43. Patel MI, DeConcini DT, Lopez-Corona E, et al.: An analysis of men with clinically localized prostate cancer who deferred definitive therapy. J Urol 2004, 171:1520–1524.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Urology, University of California, San Diego, UCSD Medical Center, 200 West Arbor Drive #8897, San Diego, CA, 92103, USA

    Christopher J. Kane

Authors
  1. Marc A. Dall’Era
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher J. Kane
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christopher J. Kane.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dall’Era, M.A., Kane, C.J. Watchful waiting versus active surveillance: Appropriate patient selection. Curr Urol Rep 9, 211–216 (2008). https://doi.org/10.1007/s11934-008-0037-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11934-008-0037-9

Keywords

Search

Navigation