Active Surveillance and Watchful Waiting for Low-risk Prostate Cancer
Active surveillance provides an important alternative to immediate treatment for early-stage, low-risk prostate cancers. For men with a relatively short life expectancy, watchful waiting is recommende
Active surveillance and watchful waiting are emerging as important management options for men diagnosed with early-stage prostate cancer.1-3 Patients do not, however, always understand the differences between these distinct approaches.
“I think the biggest difference between active surveillance and watchful waiting is the goal,” said Ronald Chen, MD, MPH, an assistant professor in the Urologic Oncology Program at the University of North Carolina in Chapel Hill.
Dr Chen co-chaired an American Society of Clinical Oncology (ASCO) expert panel that endorsed the Cancer Care Ontario Guideline on active surveillance for prostate cancer.2,3
“With active surveillance the goal is to try to cure the cancer,” Dr Chen said. “For watchful waiting, the goal is not to cure. Watchful waiting is for patients with limited life expectancy where the patient and the physician together make the decision that they're not going to pursue [treatment] anymore. With watchful waiting, the goal is not to be aggressive.”
Watchful waiting is “probably most appropriate” for men with less than 5 years' life expectancy. It is used when comorbidities are likely to cause a man's death before his prostate cancer would become a threat to his survival. When prostate cancer becomes symptomatic, patients on a watchful waiting program receive palliative care to manage those symptoms.
In contrast with watchful waiting, active surveillance involves monitoring disease over time. The goal is to monitor low-risk prostate cancer closely and to offer curative treatment if it progresses.
There is a growing evidence base showing that active surveillance is not inferior to immediate treatment, Dr Chen noted.
“Probably the best clinical trial was ProtecT, published in The New England Journal of Medicine last year,” he said.4,5 “It was a randomized trial in the United Kingdom that compared active surveillance with immediate surgery vs radiation. It showed that long-term overall survival was virtually identical between these 3 options.”
Under the ASCO endorsement of the Cancer Care Ontario Guideline, active surveillance is recommended for patients with low-risk localized prostate cancer.3 Patient age, comorbidities, and preferences are also considered.
“The term ‘active surveillance' implies actively monitoring patients and is typically the standard for low-risk patients with life expectancy longer than 5 to 10 years,” explained Brian Chapin, MD, of the MD Anderson Cancer Center in Houston, Texas.
Patients with low-volume intermediate-risk prostate cancer are also eligible, according to the ASCO endorsement.
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“Active surveillance always involves biopsies,” Dr Chen emphasized. “Usually the [second] biopsy is within a year of the first biopsy. If that looks OK, it may be every several years after that. But biopsy is always part of the active surveillance regimen.”
Once tumors grow significantly from the previous biopsy, or once disease is reclassified as high risk, patients are offered active treatment with curative intent.