Management of prostate cancer with indolent biological potential: From watchful waiting to active surveillance

Prostate cancer is the most common malignancy among elderly men. Due to its indolent course and the fact that the majority of contemporary patients are diagnosed early, disease progression to metastasis often occurs many years after the initial diagnosis. Elderly men who have concurrent severe illnesses may not experience progression to metastasis during their lifetime. Therefore, it is reasonable to withhold active therapy in some patients avoiding the associated risks, and impact on patient quality of life. Watchful waiting (WW) is an adequate approach in such cases, and has been shown to be associated with a similar overall survival when compared with radical prostatectomy. However, the disease-specific survival was better in patients who had undergone surgery. Prostate cancer patients often find it hard to persist on a WW policy. This is due to their expectation to be treated, to fight, and win the battle over cancer. Consequently, many patients who start on WW drop out and seek active treatment within several years, mostly when PSA elevation is noted. Active surveillance for prostate cancer is a novel approach consisting of avoiding the risks of therapy, while allowing the early detection of those who are prone to progress. In these high-risk individuals delayed active treatment is offered. Active surveillance consists of periodic monitoring of the PSA serum level, digital rectal exam and repeated prostate biopsies. Threshold values for these parameters are pre-defined and active therapy is instituted when such threshold values are met. Preliminary results of active surveillance show that more patients remain on a surveillance regimen as compared with the traditional WW; it is possible to offer curative treatment to individuals who were defined as having high risk by active surveillance parameters, and the disease-specific mortality is similar to that with WW. Active surveillance for prostate cancer is a novel and fascinating approach that may improve our ability to distinguish between patients who have a higher risk and need active therapy, and others in whom the risk for progression remains low and avoiding the risks of therapy is warranted.