Active surveillance
The challenge of managing localised prostate cancer is to distinguish patients with clinically relevant cancers, who may benefit from radical treatment, from the remainder who do not need any intervention. Active surveillance is a response to that challenge that offers patients the hope of avoiding ‘unnecessary’ treatment, without detriment to their long-term survival. It involves a period of monitoring with the choice between radical treatment and continued observation based on evidence of disease progression, defined by the rate of rise of PSA or by the results of repeat biopsy. The aim of active surveillance is to identify those men who need curative treatment years before any symptoms of tumour progression are evident.
Suitable patients are those who are fit for radical treatment, aged 50–80 years old, with T1–T2 disease, a Gleason score of =7 and an initial PSA of =15 (9). They are typically monitored with PSA tests at 3 to 6 month intervals, and repeat prostate biopsies every 2 to 4 years.
Watchful waiting
The term ‘watchful waiting’ has been used for decades to describe a policy of observation with the use of palliative treatment for symptomatic progression. It is very different from active surveillance. Whereas active surveillance involves close monitoring with curative treatment for those with the earliest signs of disease progression, watchful waiting involves relatively lax observation with late, palliative treatment for those who develop symptoms of progressive disease. Traditional watchful waiting remains a valid treatment option for men with asymptomatic localised or locally advanced prostate cancer who consider the benefit of treatment to be outweighed by the risk of harm. It is an attractive option for men with low grade (Gleason score < 3 + 4) disease who have a life expectancy of less than 10 years (by virtue of age or co-morbidities). It is also a valid choice for younger, fitter men with an extreme aversion to the risks of incontinence and impotence associated with radical treatment, and who place little value on their longevity.
Watchful waiting compared to other treatments
A large randomised controlled trial (RCT) involving nearly 700 men, at a median of 8.2 years follow-up, has demonstrated that radical prostatectomy slightly reduces disease-specific mortality; overall mortality (survival benefit 5% at 10 years); and the risks of metastasis and local progression when compared to watchful waiting (11). However, radical prostatectomy was associated with more erectile dysfunction and urinary leakage (30–40%), but less urinary obstruction (12). Self assessed quality of life was similar between the two groups (12).
There have been no RCTs comparing watchful waiting with active surveillance.
A systematic review of an RCT comparing immediate hormone therapy with watchful waiting found no significant difference in overall survival (13), although the authors state that the trial design makes it difficult to draw firm conclusions. Other evidence suggests that immediate hormone therapy reduces disease progression but might actually increase overall mortality (14).