One of the consequences of screening and early detection is the increasing identification of non-aggressive tumours, usually limited to small areas of low Gleason grade cancer.1 Recent prospective series confirm that these cancers can be managed with an active surveillance strategy, in which active treatment is not instigated immediately, but rather patients are monitored closely using PSA testing and repeat biopsy.1,2 Over a period of 6.8 years, 30% of patients will progress to a stage where they are still candidates for potentially curative radical therapy and the remaining patients can be spared the adverse effects of treatment.2 Identifying patients for whom active surveillance is appropriate and implementing acceptable long-term surveillance protocols is one of the most important challenges in prostate cancer today.
A second form of conservative management strategy is ‘watchful waiting.’ This is an older term dating to the pre-PSA era, in which active therapy was deferred until symptomatic progression, at which point palliative therapy could be introduced.1 Watchful waiting is still a valid option in older patients with a limited life expectancy.1 This strategy may also be considered in asymptomatic patients unfit for radical therapy, and recent data indicate that early hormonal therapy provides only a marginal survival benefit over delayed treatment.3
References:
1. European Association of Urology. Guidelines on prostate cancer, 2010.
2. Klotz L, Zhang L, Lam A, et al. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol 2010;28:126-31.
3. Studer UE, Whelan P, Albrecht W, et al. Immediate or deferred androgen deprivation for patients with prostate cancer not suitable for local treatment with curative intent: European Organisation for Research and Treatment of Cancer (EORTC) Trial 30891. J Clin Oncol 2006;24:1868-76.