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Prostate Cancer: Active Surveillance

Guidelines and review literature: (EAU Guidelines Prostate Cancer) (S3-Leitlinie Prostatakarzinom der DGU) (Walsh-Campbell Urology).

Principles of Active Surveillance in Prostate Cancer

Active surveillance is appropriate for clinically insignificant or low-risk prostate cancer when a curative treatment with potential side effects is to be avoided or deferred. If reclassification indicates a less favorable risk profile, local treatment such as radical prostatectomy or radiation therapy is initiated. Several risk stratification systems and surveillance protocols have been published to identify clinically significant cancers that require treatment. Clinical follow-up includes digital rectal examination, PSA testing, multiparametric MRI of the prostate, and prostate biopsies. The following recommendation is based on the German S3 guideline:

Inclusion Criteria for Active Surveillance:

High-quality diagnostic evaluation with multiparametric MRI and systematic plus targeted prostate biopsy is required. At least 8 biopsy cores should be available; if prostate volume exceeds 40 ml, 10–12 cores should be obtained. The following criteria should be met:

Clinical stage cT1 or cT2a
PSA < 10 ng/ml
Prostate biopsy with no more than 2 tumor-bearing cores, ≤ 50 % cancer involvement in the cores, and a Gleason score < 7
In selected patients with favorable intermediate-risk disease, active surveillance may be offered if the Gleason pattern 4 component is below 10 % and no cribriform or intraductal growth is present.

Follow-up:

Perform digital rectal examination every 6 months. Measure PSA every 3 months initially and every 6 months after 2 years. If a tumor becomes palpable or PSA rises significantly (doubling time below 3 years), repeat multiparametric MRI and prostate biopsy. Even without PSA progression, repeat multiparametric MRI with systematic and targeted prostate biopsy every 12–18 months during the first 3 years. After 3 years of stable disease, repeat biopsy with multiparametric MRI every 3 years.

Criteria for Discontinuation:

Recommend active treatment if the inclusion criteria are no longer met. If life expectancy is below 10 years when active surveillance is discontinued, watchful waiting may be continued; start androgen deprivation therapy if symptoms or rapid progression develop.

Results of Active Surveillance:

In a series of nearly 1000 patients, 76 %, 64 %, and 55 % of patients remained on active surveillance without treatment after 5, 10, and 15 years of follow-up, respectively. Prostate cancer caused death in 1.5 % of patients, and 2.8 % developed bone metastases (Klotz et al., 2015). These outcomes are comparable to those after primary treatment in patients with low-risk disease. In the randomized ProtecT trial, active monitoring and immediate curative treatment showed only small differences in the overall low rate of metastasis after 15 years (9 % vs. 5 %). Prostate cancer-specific mortality was low in all treatment groups, and 25 % of men assigned to active monitoring received no treatment (Hamdy et al., 2023).

Prostate cancer treatment options

Index

Prostate cancer prostatectomy

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

References

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Deutsche Version: Prostatakarzinom

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