Active Surveillance for Prostate Cancer with Selective Delayed Definitive Therapy

Patients diagnosed with clinically localized prostate cancer face a daunting variety of management choices, including conservative management, brachytherapy, external-beam irradiation therapy with or without neoadjuvant hormonal therapy, as well as surgery. As we have learned to characterize the nature of each cancer, we can now “riskadjust” treatment decisions. Physicians have long sought to guide patients through these choices based on their best judgment about the threat posed by the cancer, the effectiveness of treatment, the side effects of therapy, and the life expectancy of the patient. Today, many patients wish to participate more actively in decisions about their care, weighing the risks of treatment-related complications and the anxiety of living with an untreated or uncontrolled cancer. Patient utilities measure the value patients place on a health state, such as living with cancer or becoming incontinent, allowing quantitative assessments of risks and benefits of different therapeutic options specific for each patient's own preferences and the nature of his cancer and life expectancy. As early detection programs for prostate cancer expand, men are being diagnosed with prostate cancer earlier in its natural history. Some of these cancers may not require immediate treatment but rather a period of active surveillance with definitive curative therapy being administered only if there are signs of cancer progression. This review summarizes our current understanding of active surveillance with selective delayed definitive therapy.