Active surveillance for low-risk prostate cancer.

There is ample evidence that low risk and many cases of low-/intermediate-risk prostate cancer, are indolent, have little or no metastatic potential, and do not pose a threat to the patient in his lifetime. Major strides have been made in understanding who these patients are and in encouraging the use of conservative management in such individuals. A component of conservative management is the early identification of those 'low-risk' patients who harbour higher risk disease, and benefit from definitive therapy. This represents about 30% of newly diagnosed low-risk patients. A further small proportion of patients with low-risk disease demonstrate biological progression to higher grade disease. Men with lower risk disease can defer treatment, in most cases for life. Men with higher risk disease that can be localized to a relatively small volume of the prostate can undergo selective therapy. The results of active surveillance, embodying conservative management with selective delayed intervention for the subset who are re-classified as higher risk overtime based on repeat biopsy, imaging or biomarker results have shown that this approach is safe in the intermediate to long term, with a 3% cancer specific mortality at 10-15 years. Further refinement of the surveillance approach is ongoing, incorporating MRI, targeted biopsies and molecular biomarkers.