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  • Review Article
  • Published:

Active surveillance for prostate cancer: current evidence and contemporary state of practice

Nature Reviews Urology volume 13, pages 205–215 (2016)Cite this article

Subjects

Key Points

  • The nature of a given active surveillance (AS) protocol is dependent on the three core components of AS: criteria for selection, monitoring strategy, and triggers for intervention

  • Among large AS programmes, selection criteria range from very-low-risk to intermediate-risk disease, and monitoring protocols vary widely in frequency of prostate biopsy; histological upgrading is a trigger for intervention in most programmes

  • In AS cohorts with at least 5 years of available follow-up data, treatment was pursued in 24–40% of men; metastatic disease occurred in 0.1–2.8%, and prostate-cancer-specific death in 0–1.5%

  • Intermediate-term outcomes are dependent on programme-specific criteria; intensive programmes (close monitoring, low intervention thresholds) are associated with high rates of treatment and low rates of adverse oncological outcomes

  • In the absence of a single optimal AS protocol, individualizing AS intensiveness to each man's risks and expectations is a reasonable approach, only once he has been counselled on the existing data and its known limitations

  • Accurate measurement and reporting of time-dependent data are critical in order to establish reliable benchmarks for counselling and pave the way toward identifying an optimized approach

Abstract

Prostate cancer remains one of the most commonly diagnosed malignancies worldwide. Early diagnosis and curative treatment seem to improve survival in men with unfavourable-risk cancers, but significant concerns exist regarding the overdiagnosis and overtreatment of men with lower-risk cancers. To this end, active surveillance (AS) has emerged as a primary management strategy in men with favourable-risk disease, and contemporary data suggest that use of AS has increased worldwide. Although published surveillance cohorts differ by protocol, reported rates of metastatic disease and prostate-cancer-specific mortality are exceedingly low in the intermediate term (5–10 years). Such outcomes seem to be closely associated with programme-specific criteria for selection, monitoring, and intervention, suggesting that AS — like other management strategies — could be individualized based on the level of risk acceptable to patients in light of their personal preferences. Additional data are needed to better establish the risks associated with AS and to identify patient-specific characteristics that could modify prognosis.

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Figure 1: Recent years have seen a surge in the use of AS for patients with low-risk (CAPRA 0–2) prostate cancer, from a low of 6.7% between 1990 and 2009 to 40.4% between 2010 and 2013.
Figure 2: Prostate cancer is heterogeneous in nature, with a spectrum of disease ranging from indolent to highly lethal.

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Acknowledgements

S.L. is supported by the Laura & Isaac Perlmutter NYU Cancer Center (P30CA016087), the Louis Feil Charitable Lead Trust and the National Institutes of Health under Award Number K07CA178258. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Authors and Affiliations

  1. Brady Urological Institute, Johns Hopkins Medical Institutions, 600 N. Wolfe Street, Baltimore, 21287–2101, Maryland, USA

    Jeffrey J. Tosoian & H. Ballentine Carter

  2. Department of Urology, New York University, 550 1st Avenue (VZ30 #612), New York, 10016, New York, USA

    Abbey Lepor & Stacy Loeb

  3. Depatment of Population Health, New York University, 550 1st Avenue (VZ30 #612), New York, 10016, New York, USA

    Stacy Loeb

  4. The Laura & Isaac Perlmutter Cancer Center, New York University, 550 1st Avenue (VZ30 #612), New York, 10016, New York, USA

    Stacy Loeb

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Contributions

J.J.T., A.L. and S.L. researched data for the article. All authors contributed to discussion of content, wrote the manuscript, and reviewed and edited the article before submission.

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Correspondence to Jeffrey J. Tosoian.

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S.L. has acted as an advisor for Bayer Corp. The other authors declare no competing interests.

PowerPoint slides

Glossary

Favourable-risk

Defined herein as a composite group consisting of NCCN very-low-risk and low-risk prostate cancer.

Progression

A variably defined term, typically in reference to an increase in risk classification. Depending on source, progression can be defined according to any number of measures, including, but not limited, to clinical stage, serological findings, histological findings, radiographic imaging, symptomatology, and requirement of initial or additional therapies. As such, progression should be explicitly defined when used, and its use should be deferred in favour of more specific language as possible.

Reclassification

Increase in risk categorization based specifically on prostate biopsy findings; the term reclassification includes volume reclassification and grade reclassification.

National Comprehensive Cancer Network

(NCCN). An alliance of leading US cancer centres devoted to patient care, research, and education. The NCCN develops and communicates scientific, evaluative information to better inform the decision-making process between patients and physicians102.

Low-intermediate risk

A subpopulation within the NCCN intermediate-risk category that includes only those men with Gleason score 3 + 4 = 7 disease (prognostic grade group 2 as defined by Pierorazio et al.103).

Risk classification

Use of patient-specific data to classify patients according to their risk of disease recurrence or progression. Unless otherwise indicated, risk categorization is herein based upon NCCN definitions of very-low-risk, low-risk, intermediate-risk, or high-risk clinically localized disease31.

Volume reclassification

Increase in risk categorization based on increased volume of cancer on prostate biopsy. As very-low-risk cancer is the only risk category based on cancer-volume-specific criteria, volume reclassification occurs only in men harbouring very-low-risk disease.

Grade reclassification

Increase in risk categorization based on evidence of a higher grade of cancer on prostate biopsy (Gleason score upgrading). The term traditionally refers to men on AS with Gleason score 3 + 3 = 6 cancer who are subsequently found to have any Gleason pattern 4 or 5 cancer.

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Tosoian, J., Carter, H., Lepor, A. et al. Active surveillance for prostate cancer: current evidence and contemporary state of practice. Nat Rev Urol 13, 205–215 (2016). https://doi.org/10.1038/nrurol.2016.45

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