Selection of appropriate candidates for management with active surveillance

In this month’s issue of the Journal of Urology, Dr. Peter Carroll (of UCSF) and Dr. Mark Dall’Era (formerly of UCSF and now at UCDavis) have contributed an editorial entitled “What is the optimal way to select candidates for active surveillance of prostate cancer?”

In this relatively brief article they summarize our increasing knowledge about the potential benefits and risks associated with the application of active surveillance (AS) in three potential sets of patients:

  • Men with very low-risk prostate cancer
  • Men with low-risk prostate cancer
  • Men with “favorable” intermediate-risk prostate cancer

And let us be clear. No clinician can tell any one prostate cancer patient who falls into any one of these categories that they will “never” have progression of their cancer or that they will “never” die of prostate cancer. Active surveillance is not a way to “treat” prostate cancer. It is a way to avoid or at least defer treatment until it is clear that is actually necessary. Some men on active surveillance may never ever need treatment; others may only stay on active surveillance for 12 months (or even less) — but they may value that 12 months greatly for the quality of life they were able to retain prior to necessary curative treatment; and then there are always going to be patients who just can’t or don’t want to deal with the idea that they have a “chronic cancer” growing in their prostate (however slowly that may be happening, and however small the cancer).

Unfortunately for most of our readers, this article is only available on line to subscribers to the Journal of Urology, but the key conclusion reached by Carroll and Dall’Era is the following:

In the end, there may not be a single optimal set of rules to select men for AS, and guidelines should be based on patient (and partner) preferences and expectations. We know from several well described surveillance cohorts that the risk of progression to metastatic disease and dying of prostate cancer with expectant management is low, but not zero. Novel tools will undoubtedly improve risk assessment with time and change the way we treat men with prostate cancer, but the ultimate goals of any treatment and patient priorities must be identified up-front. Therefore, the criteria for patient selection should be individualized instead of combined in a one size fits all strategy based solely on avoiding prostate cancer mortality.

This seems like an extremely reasonable perspective to The “New” Prostate Cancer InfoLink. It clearly gives the patient and his family a major role in deciding what is appropriate for him. However, we would also note the clear guidance from Ann Katz — a widely recognized nurse educator — who, when asked what she would tell her husband to do if he was diagnosed with prostate cancer, says her response is that, “I would support him in making a decision that was right for him because he would have to live with the consequences of his decision.” Family members, all too often, can pressure patients into making decisions they would not, in fact, make on their own!

The combination of this perspective along with detailed information for patients and their families about the essential characteristics of patients in each of the above three groups who are “good” and “reasonable” candidates for active surveillance, along with data on the risks for progression at (say) 5, 10, 15, and 20 years, would seem to be the appropriate long-term goal.

One Response

  1. Excellent post. Thank you!

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