Watchful waiting versus active surveillance: appropriate patient selection

The prostate-specific antigen (PSA) screening era has seen dramatic stage and age migration in patients with newly diagnosed prostate cancer. The average serum PSA level of newly diagnosed patients is about 6 ng/dL, and 60% of patients are diagnosed with clinical stage T1c disease. There is evidence that many low-grade and low-stage prostate cancers have a slow growth rate and protracted clinical course, with a very low threat of metastasis or death over a prolonged interval. Many men are also appropriately concerned about the impact of prostate cancer treatment on sexual and urinary function. Therefore, delaying therapy in favor of careful surveillance, with the expectation of delivering curative treatment upon evidence of progression, is an attractive concept. In this review, we discuss active surveillance, contrast it to watchful waiting, and define common inclusion criteria. We compare follow-up regimens and discuss indications and intervention outcomes after active surveillance. Finally, we support well-designed prospective clinical trials that evaluate active surveillance compared with immediate definitive treatment.