Clinical and policy perspectives on the adoption of active surveillance for low-risk prostate cancer.

The past several decades have yielded many advances in the treatment of prostate cancer. The United States has witnessed a decline in the absolute number of deaths from prostate cancer during a period of increased screening for prostate-specific antigen (PSA) and improving treatment options. However, widespread PSA testing has also resulted in a shift in the type of tumor identified. Today, most newly diagnosed prostate cancers are low risk: low grade, nonpalpable, and confined to the prostate. An estimated 100,000 such low-risk cases are diagnosed annually. Particularly in older men, these tumors have a low probability of resulting in death, even in the absence of definitive treatment (surgery or radiation). For many patients with low-risk prostate cancer, primary definitive treatment may not maximize value in terms of promoting longevity or improving quality of life. To justify broad screening, and reduce overtreatment, it is essential to have value-based strategies for managing these cancers. Active surveillance has emerged as a management strategy for patients diagnosed with low-risk prostate cancer. It relies on routine monitoring of PSA levels, prostate biopsies, and physical examination, and reserves definitive treatment for individuals who demonstrate rapidly increasing PSA or tumor volume. Evidence is amassing, demonstrating that active surveillance with delayed intervention is noninferior and often preferable to primary definitive therapy for patients with low-risk tumors. Despite this evidence, and despite guidelines recommending the use of active surveillance, up to 90% of patients eligible for active surveillance still undergo primary definitive therapy. Growing concern regarding the overtreatment of large numbers of patients diagnosed with low-risk prostate cancer has led to recommendations for abandoning broad prostate cancer screening. In 2012, the US Preventive Services Task Force (USPSTF) officially recommended against PSA screening for the detection of prostate cancer, citing substantial rates of overdiagnosis, risk of harm from biopsy, and overtreatment of cancers that may never become symptomatic. However, simulation studies indicate that PSA screening may have contributed heavily to the gains in prostate cancer survival to date. The USPSTF’s controversial policy shift, in the long term, may lead to many men not receiving this sensitive screening test and may lead to missed opportunities for identifying and treating higher risk tumors that benefit from definitive treatment. The USPSTF’s emphasis on the overtreatment of prostate cancer highlights the need to adopt value-based management strategies, such as active surveillance, for the large number of patients who are diagnosed with low-risk prostate cancer. In this issue of Medical Care, Dr Kim and colleagues provide insight into prostate cancer specialists’ perceptions of active surveillance and potential explanations for why the majority of patients eligible for active surveillance still undergo primary definitive therapy. Dr Kim and colleagues report that although the vast majority of urologists and radiation oncologists believe that active surveillance is effective and underutilized, only a