Active surveillance with selective delayed intervention is the way to manage 'good-risk' prostate cancer

This review summarizes the case for active surveillance of 'good-risk' prostate cancer, with selective delayed intervention for rapid biochemical progression, assessed by rising prostate-specific antigen (PSA) levels or grade progression. The results of a large phase II trial using this approach are also reviewed. A prospective phase II study of active surveillance with selective delayed intervention was initiated in 1995. Patients were managed initially with surveillance; those who had a PSA doubling time (PSADT) of < or = 2 years, or grade progression on repeat biopsy, were offered radical intervention. The remaining patients were closely monitored. The cohort now consists of 299 patients with good-risk--or, in men over 70 years of age, intermediate-risk--prostate cancer. The median PSADT was 7 years, 42% had a PSADT > 10 years. The majority of patients remain on surveillance. At 8 years, overall actuarial survival was 85%, and disease-specific survival was 99%. To date, this study has shown that most men with 'good-risk' prostate cancer will die of unrelated causes. The approach of active surveillance with selective delayed intervention based on PSADT represents a practical compromise between radical therapy for all patients, 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. The results at 8 years were favorable. Longer follow-up will be required if the study is to confirm the safety of this approach in men with a long life expectancy (> 15 years).