Screen detected, low volume prostate cancer: the case for active treatment

There has been a significant increase in prostate cancer identification due to current detection methods, especially in the proportion of men with low volume, often potentially clinically indolent disease (<0.5 ml). Physicians are struggling to find an appropriate balance between undertreatment and overtreatment for men with low volume prostate cancer. Both physicians and patients alike face tough treatment decisions about the appropriate balance between the risks and benefits of therapy. Treatment decisions regarding either active surveillance or targeted focal therapy must be made with as much information as can be garnered safely. As active surveillance or targeted focal therapy protocols are developed, it would seem prudent to prospectively employ a more stringent biopsy sampling strategy. Without better tumor sampling methodologies, physicians may occasionally underestimate the extent of a patient's disease and potentially make ill-advised treatment recommendations. In the future, intraprostatic imaging models with high sensitivity could improve treatment management and outcomes. Currently, periodic PSA values and biopsies are key components of monitoring disease progression, which will likely continue into the foreseeable future. Both PSA velocity and PSA doubling time are diagnostic tools that have proven to be useful for prostate cancer detection and provide prognostic information for both localized and metastatic disease. Our goal should be to use all of these treatment tools to improve patient life expectancy and quality of life no matter what the burden level of disease happens to be.