Evolving Indications for Active Surveillance in Low-Risk Localized Prostate Cancer

Abstract

As a result of improvements in techniques for detecting prostate cancer, such as prostate-specific antigen (PSA) screening, prostate cancer is more frequently being detected while still localized within the prostate. Furthermore, the development of predictive nomograms has made it possible to estimate the risk (low, intermediate, or high) of disease progression for these patients. For some patients with low-risk, localized cancer, use of radical therapies may be inappropriate, exposing the patient unnecessarily to the traumas of surgery/radiotherapy and the concomitant complications associated with these treatment options. The protracted natural history often seen with low-risk, localized prostate cancers suggests that many of these patients may be suitable for less aggressive treatment options such as watchful waiting. Where this option is employed, a rigorous surveillance protocol is required to identify patients rapidly who are not performing well with such conservative management, and to facilitate prompt initiation of more aggressive treatment. For some patients with higher risk, non-metastatic disease, immediate hormone treatment with bicalutamide (‘Casodex’ 1 ‘Casodex’ is a trademark of the AstraZeneca group of companies. 1 ) 150 mg, which at 3 years’ median follow-up significantly improves progression-free survival compared with watchful waiting alone, could be considered as a treatment option.