Active surveillance: towards a new paradigm in the management of early prostate cancer

doi:10.1016/S1470-2045(04)01384-1

The Lancet Oncology

Volume 5, Issue 2, February 2004, Pages 101-106

https://doi.org/10.1016/S1470-2045(04)01384-1 Get rights and content

Summary

Prostate cancer is the only human cancer that is curable but which commonly does not need to be cured. Active surveillance is a new strategy that aims to individualise therapy by selecting only those men with significant cancers for curative therapy. Patients with favourable tumour characteristics are closely monitored using serum prostate specific antigen (PSA) concentrations and repeat prostate biopsies. The choice between radical treatment and continued observation is based on evidence of disease progression, defined in terms of the PSA doubling time, and “upgrading” at repeat biopsy. Active surveillance provides an excellent opportunity for studies to identify markers of prostate-cancer behaviour. Knowledge of prostate cancer biomarkers would have an immediate effect on clinical decision-making and would also identify targets for the development of novel therapeutic strategies. In the longer term, active surveillance may accelerate progress towards a new treatment paradigm for early prostate cancer based on the selective use of therapies designed, not to eradicate the disease, but to alter its natural history.

Section snippets

Some men benefit from radical treatment

Prostate cancer, unlike cancers of other sites, often has a very indolent natural history. Whereas patients with any other curable cancer would automatically be offered radical treatment, “watchful waiting” has been a recognised approach to managing prostate cancer, with acceptable results in selected patients.³ In fact, the first good evidence that some men benefit from radical treatment of localised prostate cancer has only recently become available. From 1989 to 1999, the Scandinavian

Search strategy and selection criteria

Published data for this article were identified by a MEDLINE search with combinations of the search terms: “prostatic neoplasms”, “watchful waiting”, and “conservative management”. References from relevant articles, and the author's personal collection were also included. Only articles published in English in the PSA era (since 1990) were considered. Papers were selected if they included clinical outcome data from patients with localised prostate cancer managed conservatively, but with

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Cited by (163)

Mindfulness-based stress reduction for men on active surveillance for prostate cancer and their spouses: Design and methodology of a randomized controlled trial
2023, Contemporary Clinical Trials
Although active surveillance (AS) is an increasingly adopted treatment paradigm for management of very low risk prostate cancer, many men and their partners face a variety of AS-related psychosocial stressors. Stressors may include anxiety and fear of progression, which may negatively affect short- and long-term psychosocial adjustment and influence early withdrawal from AS in order to seek definitive therapies such as surgery or radiation. Here we describe the protocol for an NCI-funded trial, which seeks to examine the efficacy of mindfulness training compared with a time/attention-matched health promotion control condition in a geographically generalizable sample of men on AS and their spouses.
Using a randomized, controlled, partially double-blinded study design, this study involves the delivery of 8 weeks of standardized mindfulness training (MBSR; mindfulness-based stress reduction) and patient reported outcomes over a 12-month period (proposed enrollment of 80 men on AS and spouses), compared with a health promotion control (proposed enrollment of 80 men on AS and spouses) that has been matched for time and attention. Baseline (T1) measures (e.g., anxiety, fear of progression, quality of life) are administered just prior to randomization to the two study arms, followed by repeated assessments at 2 months (T2), 6 months (T3) and 12 months (T4).
This study has the potential to offer men and their partners on AS with important educational and self−regulatory skills to better cope and adjust with known stressors related to being placed on this protocol.
PTPN14 acts as a candidate tumor suppressor in prostate cancer and inhibits cell proliferation and invasion through modulating LATS1/YAP signaling
2020, Molecular and Cellular Probes
Citation Excerpt :
On the basis of data from Cancer Statistics, 2019 [2], 174,650 estimated new cases of prostate cancer will be diagnosed in the United States, accounting for approximately 20% of all the estimated new cancer cases. Owning to the advance in cancer treatment and management, the therapeutic outcomes of prostate cancer patients diagnosed at early stages has remarkably improved [3,4]. However, the management and treatment of advanced or metastatic prostate cancer remains challenging [5].
Protein tyrosine phosphatase, non-receptor type 14 (PTPN14) exerts a profound effect in the progression of multiple malignant tumors. However, whether PTPN14 plays a role in prostate cancer has not been well investigated. Herein, we evaluated the function and potential underlying mechanism of PTPN14 in prostate cancer. Decreased PTPN14 expression was detected in prostate cancer, and restoration of PTPN14 expression in prostate cancer cells inhibited the proliferative and invasive potential. Mechanistically, PTPN14 increased the phosphorylation of Yes-associated protein (YAP) by activation of large tumor suppressor 1 (LATS1), an action that resulted in a significant reduction in YAP-mediated transcriptional activity. Inactivation of YAP by its inhibitor markedly abrogated the PTPN14-knockdown-induced promotion effect on prostate cancer cell proliferation and invasion. Notably, PTPN14 up-regulation also exerted a remarkable suppressive impact on tumorigenesis of prostate cancer in vivo. Taken together, the study reveals a tumor-inhibition role of PTPN14 that represses the proliferation and invasion of prostate cancer by down-regulating YAP activation.
Factors Influencing Men's Choice of and Adherence to Active Surveillance for Low-risk Prostate Cancer: A Mixed-method Systematic Review [Figure presented]
2018, European Urology
Despite support for active surveillance (AS) as a first treatment choice for men with low-risk prostate cancer (PC), this strategy is largely underutilised.
To systematically review barriers and facilitators to selecting and adhering to AS for low-risk PC.
We searched PsychINFO, PubMed, Medline 2000-now, Embase, CINAHL, and Cochrane Central databases between 2002 and 2017 using the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The Purpose, Respondents, Explanation, Findings and Significance (PREFS) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) quality criteria were applied. Forty-seven studies were identified.
Key themes emerged as factors influencing both choice and adherence to AS: (1) patient and tumour factors (age, comorbidities, knowledge, education, socioeconomic status, family history, grade, tumour volume, and fear of progression/side effects); (2) family and social support; (3) provider (speciality, communication, and attitudes); (4) healthcare organisation (geography and type of practice); and (5) health policy (guidelines, year, and awareness).
Many factors influence men's choice and adherence to AS on multiple levels. It is important to learn from the experience of other chronic health conditions as well as from institutions/countries that are making significant headway in appropriately recruiting men to AS protocols, through standardised patient information, clinician education, and nationally agreed guidelines, to ultimately decrease heterogeneity in AS practice.
We reviewed the scientific literature for factors affecting men's choice and adherence to active surveillance (AS) for low-risk prostate cancer. Our findings suggest that the use of AS could be increased by addressing a variety of factors such as information, psychosocial support, clinician education, and standardised guidelines.
Quantifying the Transition from Active Surveillance to Watchful Waiting Among Men with Very Low-risk Prostate Cancer
2017, European Urology
Active surveillance (AS) is commonly used for men with low-risk prostate cancer (PCa). When life expectancy becomes too short for curative treatment to be beneficial, a change from AS to watchful waiting (WW) follows. Little is known about this change since it is rarely documented in medical records.
To model transition from AS to WW and how this is affected by age and comorbidity among men with very low-risk PCa.
National population-based healthcare registers were used for analysis.
Using data on PCa characteristics, age, and comorbidity, a state transition model was created to estimate the probability of changes between predefined treatments to estimate transition from AS to WW.
Our estimates indicate that 48% of men with very low-risk PCa starting AS eventually changed to WW over a life course. This proportion increased with age at time of AS initiation. Within 10 yr from start of AS, 10% of men aged 55 yr and 50% of men aged 70 yr with no comorbidity at initiation changed to WW. Our prevalence simulation suggests that the number of men on WW who were previously on AS will eventually stabilise after 30 yr. A limitation is the limited information from clinical follow-up visits (eg, repeat biopsies).
We estimated that changes from AS to WW become common among men with very low-risk PCa who are elderly. This potential change to WW should be discussed with men starting on AS. Moreover, our estimates may help in planning health care resources allocated to men on AS, as the transition to WW is associated with lower demands on outpatient resources.
Changes from active surveillance to watchful waiting will become more common among men with very low-risk prostate cancer. These observations suggest that patients need to be informed about this potential change before they start on active surveillance.
Cancer screening words
2019, Bulletin du Cancer
Fifteen-year results of the ProtecT study—commentary
2023, Urologie

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ReviewActive surveillance: towards a new paradigm in the management of early prostate cancer

Summary

Section snippets

Some men benefit from radical treatment

Search strategy and selection criteria

Understanding and appreciating overdiagnosis in the PSA era

J Natl Cancer Inst

SEER Cancer Statistics Review 1973–1999

Competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer

JAMA

A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer

N Engl J Med

Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer

J Natl Cancer Inst

Overdiagnosis due to prostate-specific antigen screening: lessons from US prostate cancer incidence trends

J Natl Cancer Inst

Screening for prostate cancer: estimating the magnitude of overdetection

CMAJ

Globocan 2000. Cancer incidence, prevalence and mortality worldwide

Survival prospects after screendetection of prostate cancer

BJU Int

Quality of life after radical prostatectomy or watchful waiting

N Engl J Med

Competing risk analysis after radical prostatectomy for clinically nonmetastatic prostate adenocarcinoma according to clinical Gleason score and patient age

J Urol

Pretreatment nomogram for prostate-specific antigen recurrence after radical prostatectomy or external-beam radiation therapy for clinically localized prostate cancer

J Clin Oncol

Review
Active surveillance: towards a new paradigm in the management of early prostate cancer