Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Active surveillance for low-risk prostate cancer: selection of patients and predictors of progression

Nature Clinical Practice Urology volume 5, pages 277–283 (2008)Cite this article

Abstract

The natural history of prostate cancer is often of long duration, and the disease is incompletely understood. Whether all men with prostate cancer require immediate treatment or whether men with tumors of low malignant potential are being overtreated with potentially harmful therapies is a subject of much debate. Results from a randomized trial that compared watchful waiting and active therapy showed all-cause and disease-specific survival advantages with radical therapy, but the study group was mixed in terms of disease risk; the optimum treatment strategy for men with low risk features remains unclear. Multiple centers are gaining experience with active surveillance and delayed intervention with curative intent for men with prostate tumors of potentially low clinical risk. This Review describes the background studies behind the rationale for active surveillance, thoughts on selection criteria for candidates and some early reported outcomes for active surveillance cohorts. The psychosocial impact of active surveillance on patients is discussed as well as contemporary methods for disease monitoring.

Key Points

  • Active surveillance is a viable option for all men with low risk prostate cancer

  • Ideal candidates have features of low-risk disease on the basis of a well-performed prostate needle biopsy

  • Men must be followed up carefully with a well-planned strategy for PSA measurement, physical examination, and repeat prostate needle biopsy

  • Patient anxiety must be addressed and is a powerful driver of active treatment

  • Ongoing clinical trials will soon provide data on the optimum selection criteria and surveillance methods

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

References

  1. Jemal A et al. (2007) Cancer statistics, 2007. CA Cancer J Clin 57: 43–66

    Article  Google Scholar 

  2. Johansson JE et al. (2004) Natural history of early, localized prostate cancer. JAMA 291: 2713–2719

    Article  CAS  Google Scholar 

  3. Albertsen PC et al. (2005) 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA 293: 2095–2101

    Article  CAS  Google Scholar 

  4. Yatani R et al. (1982) Geographic pathology of latent prostatic carcinoma. Int J Cancer 29: 611–616

    Article  CAS  Google Scholar 

  5. Draisma G et al. (2003) Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer. J Natl Cancer Inst 95: 868–878

    Article  Google Scholar 

  6. Etzioni R et al. (2002) Overdiagnosis due to prostate-specific antigen screening: lessons from U.S. prostate cancer incidence trends. J Natl Cancer Inst 94: 981–990

    Article  Google Scholar 

  7. Breslow N et al. (1977) Latent carcinoma of prostate at autopsy in seven areas. The International Agency for Research on Cancer, Lyons, France. Int J Cancer 20: 680–688

    Article  CAS  Google Scholar 

  8. Byar DP and Mostofi FK (1969) Cancer of the prostate in men less than 50 years old: an analysis of 51 cases. J Urol 102: 726–733

    Article  CAS  Google Scholar 

  9. Guileyardo JM et al. (1980) Prevalence of latent prostate carcinoma in two U.S. populations. J Natl Cancer Inst 65: 311–316

    CAS  PubMed  Google Scholar 

  10. Rullis I et al. (1975) Incidence of prostatic carcinoma in the elderly. Urology 6: 295–297

    Article  CAS  Google Scholar 

  11. Wei JT et al. (2002) Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. J Clin Oncol 20: 557–566

    Article  Google Scholar 

  12. Litwin MS et al. (2007) Quality of life after surgery, external beam irradiation, or brachytherapy for early-stage prostate cancer. Cancer 109: 2239–2247

    Article  Google Scholar 

  13. Epstein JI et al. (1994) Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA 271: 368–374

    Article  CAS  Google Scholar 

  14. Greene KL et al. (2006) Prostate biopsy tumor extent but not location predicts recurrence after radical prostatectomy: results from CaPSURE. J Urol 175: 125–129

    Article  Google Scholar 

  15. Roemeling S et al. (2006) Management and survival of screen-detected prostate cancer patients who might have been suitable for active surveillance. Eur Urol 50: 475–482

    Article  Google Scholar 

  16. Carter HB et al. (2002) Expectant management of nonpalpable prostate cancer with curative intent: preliminary results. J Urol 167: 1231–1234

    Article  Google Scholar 

  17. Venkitaraman R et al. (2008) Prostate-specific antigen velocity in untreated, localized prostate cancer. BJU Int 101: 161–164

    CAS  PubMed  Google Scholar 

  18. Klotz L (2006) Active surveillance with selective delayed intervention for favorable risk prostate cancer. Urol Oncol 24: 46–50

    Article  Google Scholar 

  19. Emiliozzi P et al. (2004) Increased accuracy of biopsy Gleason score obtained by extended needle biopsy. J Urol 172: 2224–2226

    Article  CAS  Google Scholar 

  20. Vashi AR et al. (1998) A model for the number of cores per prostate biopsy based on patient age and prostate gland volume. J Urol 159: 920–924

    Article  CAS  Google Scholar 

  21. Epstein JI et al. (1997) Use of repeat sextant and transition zone biopsies for assessing extent of prostate cancer. J Urol 158: 1886–1890

    Article  CAS  Google Scholar 

  22. Partin AW et al. (2001) Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium. Urology 58: 843–848

    Article  CAS  Google Scholar 

  23. D'Amico AV et al. (1998) Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 280: 969–974

    Article  CAS  Google Scholar 

  24. Kattan MW et al. (1998) A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst 90: 766–771

    Article  CAS  Google Scholar 

  25. Cooperberg MR et al. (2005) The University of California, San Francisco Cancer of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. J Urol 173: 1938–1942

    Article  Google Scholar 

  26. Steyerberg EW et al. (2007) Prediction of indolent prostate cancer: validation and updating of a prognostic nomogram. J Urol 177: 107–112

    Article  CAS  Google Scholar 

  27. Kattan MW et al. (2003) Counseling men with prostate cancer: a nomogram for predicting the presence of small, moderately differentiated, confined tumors. J Urol 170: 1792–1797

    Article  Google Scholar 

  28. Roemeling S et al. (2007) Nomogram use for the prediction of indolent prostate cancer: impact on screen-detected populations. Cancer 110: 2218–2221

    Article  Google Scholar 

  29. Wilt TJ and Brawer MK (1997) The Prostate Cancer Intervention Versus Observation Trial (PIVOT). Oncology (Williston Park) 11: 1133–1139

    CAS  Google Scholar 

  30. D'Amico AV et al. (2004) Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy. N Engl J Med 351: 125–135

    Article  CAS  Google Scholar 

  31. D'Amico AV et al. (2005) Pretreatment PSA velocity and risk of death from prostate cancer following external beam radiation therapy. JAMA 294: 440–447

    Article  CAS  Google Scholar 

  32. Freedland SJ et al. (2005) Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA 294: 433–439

    Article  CAS  Google Scholar 

  33. Carter CA et al. (2003) Temporarily deferred therapy (watchful waiting) for men younger than 70 years and with low-risk localized prostate cancer in the prostate-specific antigen era. J Clin Oncol 21: 4001–4008

    Article  Google Scholar 

  34. Ali K et al. (2007) PSA doubling time predicts the outcome after active surveillance in screening-detected prostate cancer: results from the European randomized study of screening for prostate cancer, Sweden section. Int J Cancer 120: 170–174

    Article  CAS  Google Scholar 

  35. Stephenson AJ et al. (2002) Utility of PSA doubling time in follow-up of untreated patients with localized prostate cancer. Urology 59: 652–656

    Article  Google Scholar 

  36. Epstein JI et al. (2001) Dedifferentiation of prostate cancer grade with time in men followed expectantly for stage T1c disease. J Urol 166: 1688–1691

    Article  CAS  Google Scholar 

  37. Patel MI et al. (2004) An analysis of men with clinically localized prostate cancer who deferred definitive therapy. J Urol 171: 1520–1524

    Article  Google Scholar 

  38. Carter HB et al. (2007) Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience. J Urol 178: 2359–2364

    Article  Google Scholar 

  39. Coakley FV et al. (2003) Magnetic resonance imaging and spectroscopic imaging of prostate cancer. J Urol 170: S69–75

    Article  Google Scholar 

  40. Shukla-Dave A et al. (2007) The utility of magnetic resonance imaging and spectroscopy for predicting insignificant prostate cancer: an initial analysis. BJU Int 99: 786–793

    Article  CAS  Google Scholar 

  41. Loch T (2007) Urologic imaging for localized prostate cancer in 2007. World J Urol 25: 121–129

    Article  Google Scholar 

  42. Meng MV et al. (2003) Predictors of treatment after initial surveillance in men with prostate cancer: results from CaPSURE. J Urol 170: 2279–2283

    Article  Google Scholar 

  43. Roemeling S et al. (2006) Active surveillance for prostate cancers detected in three subsequent rounds of a screening trial: characteristics, PSA doubling times, and outcome. Eur Urol 51: 1244–1250

    Article  Google Scholar 

  44. Hardie C et al. (2005) Early outcomes of active surveillance for localized prostate cancer. BJU Int 95: 956–960

    Article  Google Scholar 

  45. Klotz L (2005) Active surveillance with selective delayed intervention is the way to manage 'good-risk' prostate cancer. Nat Clin Pract Urol 2: 136–142

    Article  Google Scholar 

  46. Martin RM et al. (2006) Continuing controversy over monitoring men with localized prostate cancer: a systematic review of programs in the prostate specific antigen era. J Urol 176: 439–449

    Article  Google Scholar 

  47. Latini DM et al. (2007) The relationship between anxiety and time to treatment for patients with prostate cancer on surveillance. J Urol 178: 826–831

    Article  Google Scholar 

  48. Wallace M (2003) Uncertainty and quality of life of older men who undergo watchful waiting for prostate cancer. Oncol Nurs Forum 30: 303–309

    Article  Google Scholar 

  49. Bailey DE et al. (2004) Uncertainty intervention for watchful waiting in prostate cancer. Cancer Nurs 27: 339–346

    Article  Google Scholar 

  50. Ornish D et al. (2005) Intensive lifestyle changes may affect the progression of prostate cancer. J Urol 174: 1065–1069

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. MA Dall'Era is a Clinical Instructor and BR Konety is an Associate Professor in the Department of Urology and UCSF Comprehensive Cancer Center, University of California, San Francisco, CA, USA.,

    Marc A Dall'Era & Badrinath R Konety

Authors
  1. Marc A Dall'Era
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Badrinath R Konety
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marc A Dall'Era.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dall'Era, M., Konety, B. Active surveillance for low-risk prostate cancer: selection of patients and predictors of progression. Nat Rev Urol 5, 277–283 (2008). https://doi.org/10.1038/ncpuro1058

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpuro1058

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing