Active surveillance is a way to monitor and manage selected men with low risk prostate cancer, that is, cancer that has not spread outside the prostate (localised prostate cancer). Some men with low grade prostate cancer on biopsy may never progress to higher stage disease or develop symptoms from their cancers therefore are suitable for active surveillance. Localised prostate cancer often grows slowly and may have a low risk of spreading so may never cause any problems or affect how long you live and as a result patients do not require treatment and may continue on the active surveillance path. The more aggressive cancer, the more high risk you are, therefore active surveillance would not be recommended.
Active surveillance involves careful monitoring and observation of the prostate cancer, with inclusion of monitoring biopsies rather than immediate active treatment in the form of surgery or radiotherapy. With careful selection, about 70% of men will not require any intervention for at least 5 years.
PSA testing has led to a considerably higher number of curable presentations. Findings from a Canadian study of 452 men by Klotz et al suggest that the 10 year survival rate of low grade prostate cancer on an active surveillance protocol was 97.2%.
Active Surveillance usually requires PSA testing every 3–4 months in the first 2 years after diagnosis, then 6 monthly thereafter. Additionally, repeat biopsies have been incorporated into all protocols.
Reasons where intervention is necessary include; if there is progression to a higher grade tumour or higher volume tumour on surveillance biopsy, there is a PSA doubling time of less than 3 years, or there is a change in patient preference towards definitive treatment
The National Institute for Health Research–supported Prostate Testing for Cancer and Treatment (ProtecT) trial recruited men 50 to 69 years of age in the United Kingdom. From 1999 to 2009, a total of 82,429 men had a PSA test; 2664 received a diagnosis of localized prostate cancer (including 146 men from the feasibility study), and 1643 agreed to undergo randomization to active monitoring, radical prostatectomy, or radiotherapy. The rate of disease progression among men assigned to prostatectomy or radiotherapy was less than half the rate among men assigned to active monitoring, as was the rate of metastatic disease. These differences show the effectiveness of immediate radical therapy over active monitoring. The majority of men who were randomly assigned to active monitoring (88%) accepted their treatment assignment, but a quarter of them received radical treatment within 3 years after their initial assignment and over half by 10 years.
Men with low grade disease should be offered active surveillance as a treatment option and provided with information about the risks and benefits of this approach.
Klotz L, Zhang L, Lam A, et al. Clinical results of long-term follow-up of a large active surveillance cohort with localised prostate cancer. J Clin Oncol 2010;28:126–31. Search PubMed
Thompson I, Klotz L. Active surveillance for prostate cancer. JAMA 2010;304:2411–2. Search PubMed