Active Surveillance for Prostate Cancer Debated

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Some evidence supports this approach, but better methods of risk-stratification are needed.

ISTANBUL—Urologists continue to argue about the merits of active surveillance, as demonstrated by a debate on this topic here at the 6th Meeting of the European Society of Oncological Urology.

Eric A. Klein, MD, chairman of the Glickman Urological & Kidney Institute and professor of surgery at the Cleveland Clinic Lerner College of Medicine in Ohio, took the position that treatment is preferable to active surveillance. The opposing point of view was taken by Freddie Hamdy, MD, Nuffield Professor of Surgery and head, Nuffield Department of Surgery, University of Oxford, United Kingdom.

Dr. Hamdy contended that most of the literature indicates that in patients with clinical evidence of indolent disease, active surveillance with PSA testing and biopsies is a middle ground between radical treatment and passive watchful waiting.

For example, in a Johns Hopkins study of 407 men with low-risk prostate cancer, active surveillance resulted in a 25% rate of treatment an average of 2.2 years after diagnosis (J Urol. 2007;178:2359-2364). The investigators concluded that “a program of careful selection and monitoring of older men who are likely to harbor small-volume, low-grade disease may be a rational alternative to the active treatment of all.”

In addition, in a study of active surveillance led by Laurence Klotz, MD, professor of surgery at the University of Toronto and chief of the division of urology at Sunnybrook Health Sciences Centre in Toronto, there was an 85% overall survival and 99.3% cancer-free survival among 299 patients at eight years (Urol Oncol. 2006;24:46-50).

As Dr. Hamdy pointed out, whether active surveillance harms patients is uncertain. In addition, the available tools for monitoring patients are inadequate because they may lead to the overdiagnosis and overtreatment of insignificant cancers and unnecessarily subject men to the adverse effects of treatment, he noted. “Overall, our duty is to discover new tools to minimize overtreatment, while making sure we do treat those who need it within a window of ‘curability.'”
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