Factors influencing patients' acceptance and adherence to active surveillance.

A number of clinical practice guidelines currently recommend active surveillance (AS) as a treatment option for low-risk localized prostate cancer. For example, the National Comprehensive Cancer Network (1) specifically recommends AS as the only treatment option for men with less than a 20-year life expectancy and very low-risk disease (defined as prostate-specific antigen [PSA] <10ng/mL, Gleason sum 6 or less, stage T1c, less than three biopsy cores positive with less than 50% cancer involvement in all cores, and PSA density <0.15ng/ml/cm3) or men with low-risk disease (Gleason sum 6 or less, stage T1c–T2a, and PSA <10ng/mL) with less than a 10-year life expectancy. In cases of men with either 1) very low-risk disease and more than a 20-year life expectancy, 2) low-risk disease and greater than a 10-year life expectancy, or 3) intermediate risk disease (Gleason sum 7, stage T2b–T2c, or PSA 10–20ng/mL), the National Comprehensive Cancer Network guidelines recommend that AS be offered as a possible option for primary treatment, along with surgery or radiation. Similarly, the 2007 guidelines on the management of clinically localized prostate cancer issued by the American Urological Association (2) recommend that all patients with clinically localized prostate cancer be informed of AS, surgery, and radiation as potential treatment options as a standard. In the case of low- and intermediate risk disease in particular, the American Urological Association guidelines specifically suggest that AS is a reasonable treatment option. Despite these recommendations, AS is generally underutilized in men with clinically localized prostate cancer. For example, Cooperberg et al. (3) analyzed data from 11 869 participants in the Cancer of the Prostate Strategic Urologic Research Endeavor program, an observational disease registry of men with prostate cancer diagnosed at 35 urologic practices across the United States. Although 36% of men had low-risk disease and 36% had intermediate risk disease, only 7% elected AS. Data from the Prostate Cancer Outcomes Study, a population-based cohort of men diagnosed with prostate cancer in 1994 and 1995, noted a higher rate of “conservative management” (18% of 3073 participants with clinically localized disease) but still less than what would be expected given the age and tumor risk distribution of the cohort (4). These data underscore the fact that there appear to be barriers to the use of AS in clinically localized prostate cancer. In broadest terms, barriers can be categorized into two domains: physician-related and patient-related. As will be discussed later, physician recommendation plays a critical role in patient acceptance of AS. If the physician fails to discuss AS, or worse actively discourages the option, it is unlikely that the patient will accept this therapeutic option (5). A discussion of physician-related barriers to the acceptance of AS, however, is beyond the scope of this review. Rather, this chapter will focus specifically on patient-related factors that influence the acceptance of and adherence to AS in clinically localized prostate cancer. Specifically, we will first discuss the exact factors that patients weigh when considering therapies for localized disease, with particular attention to why they accept or reject AS. We will then consider how patients’ perceptions of these factors are influenced by others, specifically their physicians, family members, and friends. Finally, after discussing what factors determine patient acceptance of AS, we will discuss what influences adherence after men have decided to pursue AS as a therapeutic option for clinically localized disease. By identifying and reviewing the patient-related factors that influence acceptance of and adherence to AS, we may begin to increase utilization of this treatment strategy in appropriate patients, reducing overtreatment, and potentially improving patient-centered outcomes in this common malignancy.