Inspired by Prostate CancerAwareness Month (September),I wondered what would be consideredthe most noteworthy advancein prostate cancer (PCa) managementin the past 10 years. The possibilitiesare many, but certainly scientific andtherapeutic advances in metastaticcastration-resistant PCa that haveextended survival by 4–5 monthson average must figure large in myanalysis, given that PCa causes anestimated 27,540 deaths annually. The therapeutics include sipuleucel-T(a therapeutic vaccine) and radium-223, a first-in-class drug that targetsbone metastases with alpha particles, as well as abiraterone acetate,enzalutamide, and cabazitaxel. Clinicians now have available an arrayof therapeutic choices with which to manage a clinically challenginggroup of patients.
Although using therapeutics to prolong life is a major goal of medicine,I cannot ignore advances in the screening and management oflow-risk PCa that address the formidable challenge of decreasingPCa overtreatment. Multiple randomized trials have shown that thevast majority of prostate tumors have an indolent course, seldommetastasizing and causing death. It became clear that many men withlow-risk PCa could safely avoid radical treatment without shorteningtheir lifespan. The result was the emergence of active surveillance as areasonable first-line management strategy for selected patients.
Today,many institutions have protocols for monitoring patients for diseaseprogression, offering active treatment when appropriate. Guidelinesfrom the National Comprehensive Cancer Network recommend activesurveillance as the sole initial treatment for men with low-risk diseaseand a life expectancy of less than 10 years and men with very-low-riskdisease and a life expectancy of less than 20 years. Guidelines from theAmerican Urological Association and European Association of Urologyalso recommend that active surveillance be considered among thefirst-line management approaches for clinically localized low-risk PCa.
Active surveillance has the potential to spare thousands of patientsthe complications of radical surgery or radiotherapy (especially erectile dysfunction and urinary incontinence) that can adversely affect qualityof life. Although data suggest that active surveillance is underused, thismay change as confidence in this management strategy grows. Recentstudies may bolster that confidence. For example, some investigationshave identified biomarkers that can accurately distinguish betweenindolent and aggressive tumors, which could assist in risk-stratifyingpatients. Greater certainty of a tumor’s indolence may translate intomore confidence in active surveillance as a management strategy.New treatments that take patient care in a new and positive directionare a great thing, but so are the medical advances that help patientsavoid jumping into treatment unless it is necessary.