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Systematic Review and Meta-analysis of Factors Determining Change to Radical Treatment in Active Surveillance for Localized Prostate Cancer

Eur Urol. 2015 Jun;67(6):993-1005.

Abstract

Context

Many men with clinically localized prostate cancer are being monitored as part of active surveillance (AS) programs, but little is known about reasons for receiving radical treatment.

Objectives

A systematic review of the evidence about AS was undertaken, with a meta-analysis to identify predictors of radical treatment.

Evidence acquisition

A comprehensive search of the Embase, MEDLINE and Web of Knowledge databases to March 2014 was performed. Studies reporting on men with localized prostate cancer followed by AS or monitoring were included. AS was defined where objective eligibility criteria, management strategies, and triggers for clinical review or radical treatment were reported.

Evidence synthesis

The 26 AS cohorts included 7627 men, with a median follow-up of 3.5 yr (range of medians 1.5–7.5 yr). The cohorts had a wide range of inclusion criteria, monitoring protocols, and triggers for radical treatment. There were eight prostate cancer deaths and five cases of metastases in 24 981 person-years of follow-up. Each year, 8.8% of men (95% confidence interval 6.7–11.0%) received radical treatment, most commonly because of biopsy findings, prostate-specific antigen triggers, or patient choice driven by anxiety. Studies in which most men changed treatment were those including only low-risk Gleason score 6 disease and scheduled rebiopsies.

Conclusions

The wide variety of AS protocols and lack of robust evidence make firm conclusions difficult. Currently, patients and clinicians have to make judgments about the balance of risks and benefits in AS protocols. The publication of robust evidence from randomized trials and longer-term follow-up of cohorts is urgently required.

Patient summary

We reviewed 26 studies of men on active surveillance for prostate cancer. There was evidence that studies including men with the lowest risk disease and scheduled rebiopsy had higher rates of radical treatment.

Take Home Message

We identified 26 studies including 7627 men on active surveillance. There were few prostate cancer deaths. Programs with a scheduled rebiopsy and including only men with Gleason 3 + 3 scores had the highest rates of change to radical treatment.

Keywords: Active monitoring, Active surveillance, Conservative management, Deferred treatment, Expectant management, Localized prostate cancer, Meta-analysis, Prostatic neoplasms, Systematic review, Watchful waiting.

Footnotes

a School of Social and Community Medicine, University of Bristol, Bristol, UK

b NIHR Bristol Nutrition Biomedical Research Unit, University of Bristol, Bristol, UK

c Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

d Guy's Hospital, London, UK

e Cancer Research UK, Cambridge Research Institute, Cambridge, UK

lowast Corresponding author. School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol BS8 2PS, UK. Tel. +44 117 3314520; Fax: +44 117 9287325.

These authors contributed equally.