Active Surveillance versus Initial Treatment in Low-Risk Prostate Cancer

There were 192,000 men diagnosed with prostate cancer in the United States in 2009; of those men, 70% will have been classified as having low-risk, clinically localized disease and >90% will have undergone initial treatment including surgical resection or radiation therapy. More than half of men undergoing initial treatment experience at least 1 adverse event related to treatment. With the introduction of prostate-specific antigen (PSA) screening, as many as 60% of men diagnosed with prostate cancer may not require therapy; however, it is not currently possible to identify men who require treatment to avoid prostate cancer morbidity and mortality from those who will die with but not because of their cancer. Active surveillance, a possible alternative to initial treatment for men with low-risk, clinically localized disease, may mitigate overtreatment. Active surveillance is defined as a strategy of close monitoring for carefully selected patients who present with low-risk prostate cancer. There have been several observational cohorts of active surveillance with promising results, but to date all studies have had short follow-up periods. Researchers recently conducted a decision analysis to assess the quality-adjusted life expectancy (QALE) of active surveillance compared with initial definitive treatment with radical prostatectomy, intensity-modulated radiation therapy (IMRT), or brachytherapy. They reported results in the Journal of the American Medical Association [2010;304(21):2373-2380]. The patients were hypothetical cohorts of men 65 years of age with new diagnoses of clinically localized, low-risk prostate cancer (PSA level <10 ng/mL, stage