Active surveillance with selective delayed intervention using PSA doubling time for good risk prostate cancer

Good risk prostate cancer, defined as patients with a Gleason score of 6 or less, PSA<10-15, and T1c-T2a, now constitutes 50% of newly diagnosed prostate cancer. For most of these patients, the disease is indolent and slow growing. There is substantial evidence that it does not pose a threat during the lifetime of most patients. The challenge is to identify those patients who are not likely to experience significant progression while offering radical therapy to those who are at risk. To date, molecular markers have failed to provide sufficiently reliable predictive information to influence decision making. The approach to favorable risk prostate cancer described in this article uses estimation of PSA doubling time (PSA DT) to stratify patients according to the risk of progression. Patients who select this approach are managed initially with active surveillance. those who have a PSA DT of 3 years or less (based on a minimum of 3 determinations over 6 months) are offered radical intervention. The remainder are closely monitored with serial PSA and periodic prostate re-biopsies (at 2, 5, and 10 years). In this series of 299 patients, the median doubling time was 7.0 years. 42% had a PSA DT>10 years, and 20% had a PSA DT>100 years. The majority of patients in this study remain on surveillance. The approach of active surveillance with selective delayed intervention based on PSA DT represents a practical compromise between radical therapy for all (which results in overtreatment for patients with indolent disease), and watchful waiting with palliative therapy only (which results in undertreatment for those with aggressive disease).