Expectant management for early prostate cancer

See Surveillance for prostate cancer

Refers to no definitive treatment following prostate cancer diagnosis.

Surveillance therapy increasing in patients unlikely to benefit from immediate therapy.

Expectant management encompasses all approaches that defer or avoid treatment by surveillance after a diagnosis of prostate cancer is made.

Expectant management is divided into watchful waiting and active surveillance.

Watchful waiting protocols do not involve aggressive testing or intervention, but await the symptomatic evidence of progressive disease before further critical evaluation.

Watchful waiting is usually use for elderly patients with those with multiple comorbidities who are unlikely to benefit from curative treatment approach, and any treatment is focused on palliation.

Active surveillance programs maintain the opportunity of curing more aggressive disease by structured monitoring with PSA testing or repeat prostate biopsy which attempts to identify any change in disease risk, that is, an increased Gleason score, that would merit definitive therapy.

Active surveillance includes periodic surveillance biopsies, in addition to PSA monitoring, with a plan to initiate local therapy with curative intent if there is evidence of disease progression.

Men with minimally aggressive PC managed with watchful waiting, particularly those older than age 65, have a greater likelihood of dying from something other than prostate cancer.

Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) trial demonstrated that radical prostatectomy vs watchful waiting: benefits were not evident in men over the age of 65 years from surgery.

In the Prostate Cancer Intervention Versus Observation Trial (PIVOT) a VA study of localized prostate cancer for the randomization to either radical prostatectomy or watchful,waiting: survival benefits of aggressive treatment were limited to those with the PSA greater than 10 ng for those with higher risk prostate tumors.

In the above study, notably only 8% of men randomized to observation only, and 6% of the low risk patients died of prostate cancer after 15 years of follow up.

Men undergoing radical prostatectomy who have low risk tumors identified pathologically have less than a 1% chance of subsequent prostate specific cancer mortality.

Up to 33% of men initially classified with low risk tumors are upstaged or upgraded to intermediate risk or high risk disease at radical prostatectomy.

There is a subset of men who are misclassified with low risk prostate cancer at the time of their initial biopsy but who are ultimately found to have more aggressive disease.

Active active surveillance is a safe treatment option for low and very low risk prostate cancer, regardless of race: African-American and White American men did not have any significant difference in Gleason grade group progression in a five-year follow up study (Pincus J).

After 15 years of follow up prostate cancer specific mortality was low regardless of the treatment assigned: between monitoring, surgery or radiation (ProecT study group).

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