Active Surveillance for Prostate Cancer: How to Do It Right.

Prostate cancer is the most common malignancy affecting men. There has been a nearly 70% increase in new prostate cancer cases, mostly classified as low risk, that have been diagnosed in early stages as a consequence of prostate-specific antigen (PSA) screening. Data regarding the natural history of this disease confirm the clinical insignificance of low-grade prostate cancer, which is associated with scant or no metastatic dissemination. Active surveillance is a conservative management approach, conducted for those patients with "low-risk" or "favorable-risk" disease, which avoids long-term adverse effects on the patient's quality of life. It is characterized by a routine protocol of close monitoring with digital rectal examination, periodic biopsy, and serial PSA testing. As defined by D'Amico, active surveillance is broadly appropriate for men with a Gleason score of 6 or less and a PSA level of less than 10 ng/mL. Typically, Gleason pattern 3 disease lacks the common genetic aberrancies of a true cancer. An essential element of the active surveillance approach is early recognition of higher-risk disease, which is diagnosed by systematic biopsy in 30% of patients who initiate active surveillance with low-risk disease. Also, a small group of patients have molecular alterations that can cause progression to more aggressive disease; these men can be switched to immediate treatment if such progression is detected. Oncologic outcomes for active surveillance cohorts have shown the long-term safety of this approach, with a cancer-specific mortality rate of 3% at 10 to 15 years. In this review of active surveillance for favorable-risk prostate cancer, we will discuss the rationality of this approach, the biological evidence for employing active surveillance in Gleason pattern 3 and 4 prostate cancer, patient selection for active surveillance, clinical trial data on active surveillance, and the role of prostate cancer biomarkers and imaging studies (MRI) for clinical decision making in patients with low-risk disease.