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:

Treatment of localized prostate cancer: when is active surveillance appropriate?

Nature Reviews Clinical Oncology volume 7, pages 394–400 (2010)Cite this article

Subjects

Abstract

Testing for prostate-specific antigen (PSA) has caused a dramatic increase in the incidence of prostate cancer during the past two decades. Many cancers identified by repeated PSA testing are small volume, low-grade lesions that pose little threat of progression over 15–20 years. Data from a recently reported randomized trial indicate that as many as 48 men must undergo treatment to prevent one prostate cancer-related death. Unfortunately, no test is currently available that can identify those men who have clinically significant disease. Men least likely to experience disease progression are men who harbor tumors with a Gleason score of 6 involving 2 needle cores or less; these men may want to consider active surveillance as their initial treatment option. Researchers have followed over 2,500 men on active surveillance protocols (over 200 men have been followed for >10 years). To date, prostate cancer-specific survival is over 99%. About 25% of men enrolled in active surveillance programs have abandoned this approach because of concerns about disease progression. For men harboring tumors with a Gleason score >7, data from two recently reported Swedish trials suggest lower prostate cancer-related mortality for those men receiving either surgery or radiation.

Key Points

  • Testing for prostate specific antigen (PSA) has dramatically increased the incidence of localized prostate cancer

  • Many cancers identified as a consequence of PSA testing are clinically insignificant

  • No current diagnostic tools or biological markers can reliably differentiate between indolent disease and aggressive disease

  • Men with palpable disease or a Gleason score ≥7 have a significant risk of disease progression in the absence of aggressive treatment with either surgery or radiation

  • Men with low-volume disease and a Gleason score ≤6 may wish to consider active surveillance, but this approach should be regarded as experimental until more data become available

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

Figure 1: Survival and cumulative mortality from prostate cancer and other causes up to 20 years after diagnosis, stratified by age at diagnosis and Gleason score.

Similar content being viewed by others

References

  1. Jemal, A. et al. Cancer statistics, 2009. CA Cancer J. Clin. 59, 225–249 (2009).

    Article  Google Scholar 

  2. Cooperberg, M. R., Lubeck, D. P., Meng, M. V., Mehta, S. S. & Carroll, P. R. The changing face of low-risk prostate cancer: trends in clinical presentation and primary management. J. Clin. Oncol. 22, 2141–2149 (2004).

    Article  Google Scholar 

  3. Dall'Era, M. A. et al. Active surveillance for early-stage prostate cancer: review of the current literature. Cancer 112, 1650–1659 (2008).

    Article  Google Scholar 

  4. Schröder, F. H. et al. Screening and prostate cancer mortality in a randomized European study. N. Engl. J. Med. 360, 1320–1328 (2009).

    Article  Google Scholar 

  5. Andriole, G. L. et al. Mortality results from a randomized prostate cancer screening trial. N. Engl. J. Med. 360, 1310–1319 (2009).

    Article  CAS  Google Scholar 

  6. Epstein, J. I., Walsh, P. C., Carmichael, M. & Brendler, C. B. Pathological and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA 271, 368–374 (1994).

    Article  CAS  Google Scholar 

  7. Lughezzani, F. et al. Head-to-head comparison of the three most commonly used preoperative models for prediction of biochemical recurrence after radical prostatectomy. Eur. Urol. 57, 562–568 (2010).

    Article  Google Scholar 

  8. Thompson, I. M. et al. The influence of finasteride on the development of prostate cancer. N. Engl. J. Med. 349, 215–224 (2003).

    Article  CAS  Google Scholar 

  9. Shariat, S. F., Karakiewicz, P. I., Roehrborn, C. G. & Kattan, M. W. An updated catalog of prostate cancer predictive tools. Cancer 113, 3075–3099 (2008).

    Article  Google Scholar 

  10. Partin, A. W. et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA 277, 1445–1451 (1997).

    Article  CAS  Google Scholar 

  11. Yu, J. B. et al. Validation of the partin nomogram for prostate cancer in a national sample. J. Urol. 183, 105–111 (2010).

    Article  Google Scholar 

  12. Eyre, S. J. et al. Validation in a multiple urology practice cohort of the Prostate Cancer Prevention Trial calculator for predicting prostate cancer detection. J. Urol. 182, 2653–2658 (2009).

    Article  Google Scholar 

  13. Shariat, S. F., Kattan, M. W., Vickers, A. J., Karakiewicz, P. I. & Scardino, P. T. Critical review of prostate cancer predictive tools. Future Oncol. 5, 1555–1584 (2009).

    Article  Google Scholar 

  14. Albertsen, P. C., Hanley, J. A. & Fine, J. 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA 293, 2095–2101 (2005).

    Article  CAS  Google Scholar 

  15. Lu-Yao, G. L. et al. Outcomes of localized prostate cancer following conservative management. JAMA 302, 1202–1209 (2009).

    Article  CAS  Google Scholar 

  16. Welch, A. G. & Albertsen, P. C. Prostate cancer diagnosis and treatment after the introduction of prostate specific antigen screening: 1986–2005 J. Natl Cancer Inst. 101, 1325–1329 (2009).

    Article  Google Scholar 

  17. Draisma, G. et al. 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 (2003).

    Article  Google Scholar 

  18. Collin, S. M. et al. Prostate-cancer mortality in the USA and UK in 1975–2004: an ecological study. Lancet Oncol. 9, 445–452 (2008).

    Article  Google Scholar 

  19. Presti, J. C. Jr, O'Dowd, G. J., Miller, M. C., Mattu, R. & Veltri, R. W. Extended peripheral zone biopsy schemes increase cancer detection rates and minimize variance in prostate specific and age related cancer rates: results of a community multi-practice study. J. Urol. 169, 125–129 (2003).

    Article  Google Scholar 

  20. Gleason, D. F. & Mellinger, G. T. Predication of prognosis for prostatic adenocarcinoma by combined histologic grading and clinical staging. J. Urol. 111, 58–64 (1974).

    Article  CAS  Google Scholar 

  21. Epstein, J. I. Gleason score 2–4 adenocarcinoma of the prostate on needle biopsy: a diagnosis that should not be made. Am. J. Surg. Pathol. 24, 477–478 (2000).

    Article  CAS  Google Scholar 

  22. Albertsen, P. C. et al. Prostate cancer and the Will Rogers phenomenon. J. Natl Cancer Inst. 97, 1248–1253 (2005).

    Article  Google Scholar 

  23. Johansson, J. E. et al. Natural history of early, localized prostate cancer. JAMA 291, 2713–2719 (2004).

    Article  CAS  Google Scholar 

  24. Bill-Axelson, A. et al. Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. J. Natl Cancer Inst. 100, 1144–1154 (2008).

    Article  Google Scholar 

  25. Widmark, A. et al. Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomized phase III trial. Lancet 373, 301–308 (2009).

    Article  CAS  Google Scholar 

  26. Klotz, L. et al. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J. Clin. Oncol. 28, 126–131 (2010).

    Article  Google Scholar 

  27. van As, N. J. et al. Predicting the probability of deferred radical treatment for localised prostate cancer managed by active surveillance. Eur. Urol. 54, 1297–1305 (2008).

    Article  Google Scholar 

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

    Article  Google Scholar 

  29. Soloway, M. S. et al. Active surveillance; a reasonable management alternative for patients with prostate cancer: the Miami experience. BJU Int. 101, 165–169 (2008).

    PubMed  Google Scholar 

  30. van den Bergh, R. C. et al. Outcomes of men with screen detected prostate cancer eligible for active surveillance who were managed expectantly. Eur. Urol. 55, 1–8 (2009).

    Article  Google Scholar 

  31. Khatami, A. et al. 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 (2007).

    Article  Google Scholar 

  32. Dall'Era, M. A. et al. Active surveillance for the management of prostate cancer in a contemporary cohort. Cancer 112, 2664–2670 (2008).

    Article  Google Scholar 

  33. Johansson, E. et al. Time, symptom burden, androgen deprivation, and self-assessed quality of life after radical prostatectomy or watchful waiting: the Randomized Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) clinical trial. Eur. Urol. 55, 422–430 (2009).

    Article  Google Scholar 

  34. Shappley, W. V. 3rd et al. Prospective study of determinants and outcomes of deferred treatment or watchful waiting among men with prostate cancer in a nationwide cohort. J. Clin. Oncol. 27, 4980–4985 (2009).

    Article  Google Scholar 

  35. Eastham, J. A. et al. Variation of serum prostate-specific antigen levels: an evaluation of year-to-year fluctuations. JAMA 289, 2695–2700 (2003).

    Article  CAS  Google Scholar 

  36. Fujita, K., Landis, P., McNeil, B. K. & Pavlovich, C. P. Serial prostate biopsies are associated with an increased risk of erectile dysfunction in men with prostate cancer on active surveillance. J. Urol. 182, 2664–2669 (2009).

    Article  Google Scholar 

  37. Sanda, M. G. et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N. Engl. J. Med. 358, 1250–1261 (2008).

    Article  CAS  Google Scholar 

  38. Miller, D. C. et al. Long-term outcomes among localized prostate cancer survivors: health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy. J. Clin. Oncol. 23, 2772–2780 (2005).

    Article  Google Scholar 

  39. Huggins, C. & Hodges, C. V. Studies on prostatic cancer: I. The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. Cancer Res. 1, 293–297 (1941).

    CAS  Google Scholar 

  40. Bolla, M. et al. Duration of androgen suppression in the treatment of prostate cancer. N. Engl. J. Med. 360, 2516–2527 (2009).

    Article  CAS  Google Scholar 

  41. Cooperberg, M. R., Grossfeld, G. D., Lubeck, D. P. & Carroll, P. R. National practice patterns and time trends in androgen ablation for localized prostate cancer. J. Natl Cancer Inst. 95, 981–989 (2003).

    Article  Google Scholar 

  42. Abrahamsson, P. A. et al. Risks and benefits of hormonal manipulation as monotherapy or adjuvant treatment in localised prostate cancer. Eur. Urol. 48, 900–905 (2005).

    Article  Google Scholar 

  43. Lu-Yao, G. L. et al. Survival following primary androgen deprivation therapy among men with localized prostate cancer. JAMA 300, 173–181 (2008).

    Article  CAS  Google Scholar 

  44. Shahinian, V. B., Kuo, Y. F., Freeman, J. L. & Goodwin, J. S. Risk of the “androgen deprivation syndrome” in men receiving androgen deprivation for prostate cancer. Arch. Intern. Med. 166, 465–471 (2006).

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, 06030, CT, USA

    Peter C. Albertsen

Authors
  1. Peter C. Albertsen
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Albertsen, P. Treatment of localized prostate cancer: when is active surveillance appropriate?. Nat Rev Clin Oncol 7, 394–400 (2010). https://doi.org/10.1038/nrclinonc.2010.63

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrclinonc.2010.63

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer