Chapter 25 - Expectant Management in 2002: Rationale and Indications

Abstract

The optimal management of clinically localized prostate cancer remains unresolved. Management options are diverse, varying from a conservative approach (expectant management) to definitive treatment (radical prostatectomy or radiotherapy). Several studies have suggested that expectant management provides similar 10-year survival rates and quality-adjusted life years compared with radical prostatectomy or radiotherapy. Expectant management alone, however, clearly deprives some patients with potentially curable life-threatening disease of the opportunity for curative therapy. The dilemma of management stems from the heterogeneity of the natural history of prostate cancer. While these statistics suggest a high incidence of “latent” prostate cancer and a slow natural history of prostate cancer in many patients, they also indicate that the risk of dying from clinically diagnosed prostate cancer is substantial. This conundrum is the rationale for both conservative management and radical treatment. The approach of watchful waiting with selective intervention for patients with rapid biochemical or clinical progression is feasible. Watchful waiting is clearly appropriate for patients who are elderly, have significant comorbidity and have favorable clinical parameters. The use of comorbidity indices like the Index of Co-Existent Disease (ICED) facilitate the identification of patients whose life expectancy is diminished relative to the natural history of their prostate cancer.