Commentary on the State-of-the-Science Conference on the role of active surveillance in the management of men with localized prostate cancer.

The Centers for Disease Control and Prevention, in collaboration with the partners and experts within the cancer community, is pleased to support this monograph, which summarizes the state of the scientific evidence and current research from experts on issues surrounding active surveillance and document opportunities for future research to optimize its use as a treatment strategy for men with localized prostate cancer. The American Cancer Society estimates that greater than 240000 cases will be diagnosed this year (1). Prostate-specific antigen (PSA) testing has changed the presentation of prostate cancer diagnoses over time; contemporary PSA testing practices have led to more men being diagnosed with early-stage prostate cancer (2). An estimated 90% of all prostate cancers are discovered in the local or regional stages and have a 5-year relative survival rate approaching 100% (1). Despite the high probability of survival, about 90% of men diagnosed with prostate cancer undergo definitive therapy with curative intent (3,4), unnecessarily risking side effects and complications of treatment (5), including death. A large proportion of these men could possibly benefit from observational strategies and delayed treatment. Active surveillance and other observational strategies have emerged as viable alternative options to immediate treatment that should be offered to men with low-risk prostate cancer. Although studies (6–8) indicate the feasibility and rationale for offering active surveillance to men with early-stage, low-risk prostate cancer, questions remain regarding adequate identification of patients who would likely benefit from this intervention. Given the high prevalence of PSA-detected, low-risk prostate cancer, there was an important need to clarify the role of active surveillance in the disease management of present-day patients who on an average are younger, have fewer comorbidities, and longer life expectancy and to better understand the benefits and risks of strategies using delayed treatment. To address these issues, the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control and the National Cancer Institute cosponsored a National Institutes of Health (NIH) State-of the-Science Conference on December 5–7, 2011, in Bethesda, MD, to begin to address the following: Which newly-diagnosed men should be considered viable candidates for active surveillance (AS)? What are the tumor and patient behavioral characteristics of a good candidate? What evidence needs to be generated to allow identification of appropriate candidates for AS? What constitutes an appropriate follow-up regimen for active surveillance? What physicians should perform AS (urologists or primary care)? What specific tests should be part of AS and at what frequency? Should AS monitoring include health-related quality-of-life issues (eg, anxiety, pain, genitourinary symptoms)? How can patient acceptance of active surveillance as a management tool be improved? Are there healthcare cost savings associated with delayed treatment? The Conference convened an impressive roster of prostate cancer researchers, thought leaders, and patient advocates from around the world to examine the current state of scientific knowledge on AS as a management strategy for localized prostate cancer. The panel addressed the following key questions: How have the patient population and the natural history of prostate cancer diagnosed in the United States changed in the last 30 years? How are AS and other observational strategies defined? What factors affect the offer of, acceptance of, and adherence to AS? What are the patient-experienced comparative short- and long-term health outcomes of AS vs immediate treatment with curative intent for localized prostate cancer? What are the research needs regarding AS in localized prostate cancer? Given the many unanswered questions about AS strategies and prostate cancer, panel discussions concluded that additional research and clarification are necessary, particularly to delineate improvements in the accuracy and consistency of pathological diagnosis of prostate cancer; provide consensus on the most appropriate candidates for AS; discuss the optimal protocol for AS and the potential for individualizing the approach based on clinical and patient factors; proffer optimal ways to communicate the option of AS to patients; improve methods to assist patient decision making; understand patients’ and physicians’ reasons for acceptance or rejection of AS as a treatment strategy; and summarize the short- and long-term outcomes of AS. In conclusion, this monograph addresses the key questions discussed at the Conference, emerging issues to consider, as well as areas of future research relative to AS. The full-length final panel statement, by Ganz et al., was originally published in Annals of Internal Medicine (9), and is reproduced below.