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  • Review Article
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Active surveillance for prostate cancer: a narrative review of clinical guidelines

Nature Reviews Urology volume 13, pages 151–167 (2016)Cite this article

Subjects

Key Points

  • A number of guidelines have been published that include criteria for active surveillance (AS) enrolment and subsequent management to assist clinicians and patients in critically important treatment related decision-making

  • Consensus on inclusion criteria, surveillance schedules and intervention thresholds is currently lacking

  • The future of AS and its uptake as a management modality will depend on better patient selection and validated monitoring schedules to improve identification of disease progression

  • Combining existing evidence and gathering more long-term evidence is needed to derive a broadly supported guideline to reduce variations in clinical practice and to optimize clinical decision-making

Abstract

In the past decade active surveillance (AS) of men with localized prostate cancer has become an increasingly popular management option, and a range of clinical guidelines have been published on this topic. Existing guidelines regarding AS for prostate cancer vary widely, but predominantly state that the most suitable patients for AS are those with pretreatment clinical stage T1c or T2 tumours, serum PSA levels <10 ng/ml, biopsy Gleason scores of 6 or less, a maximum of one or two tumour-positive biopsy core samples and/or a maximum of 50% of cancer per core sample. Following initiation of an AS programme, most guidelines recommend serial serum PSA measurements, digital rectal examinations and surveillance biopsies to check for and identify pathological indications of tumour progression. Definitions of disease reclassification and progression differ among guidelines and multiple criteria for initiation of definitive treatment are proposed. The variety of descriptions of criteria for clinically insignificant prostate cancer indicates a lack of consensus on optimal AS and intervention thresholds. A single set of guidelines are needed in order to reduce variations in clinical practice and to optimize clinical decision-making. To enable truly evidence-based guidelines, further research that combines existing evidence, while also gathering information from more long-term studies is needed.

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Acknowledgements

This study is linked to a larger project, the Movember Foundation's Global Action Plan on active surveillance for low-risk prostate cancer (GAP3), which is collaboration between institutions, hospitals and research centres in Australia, Canada, France, Finland, Italy, Japan, Netherlands, UK and the USA. The Movember Foundation has invested €1,664,950 in the GAP3 project in order to create the largest centralized database on AS in men with prostate cancer to date, comprising around 40% of all global patient data on AS. The funder did not play any role in the study design, collection, analysis or interpretation of data, or in the drafting of this paper.

Author information

Authors and Affiliations

  1. Department of Urology, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, Netherlands

    Sophie M. Bruinsma, Chris H. Bangma, Leonard P. Bokhorst & Monique J. Roobol

  2. Department of Urology, 550 16th Street, University of California, San Francisco, Mailbox Code 1695, San Francisco, 94143, California, USA

    Peter R. Carroll & Michael S. Leapman

  3. Department of Urology, Helsinki University Central Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland

    Antti Rannikko

  4. Urology Research, University College London & University College London Hospitals Trust, 132 Hampstead Road, NW1 2PS, London, UK

    Neophytos Petrides

  5. Department of Surgery, Austin Hospital, Level 8 Harold Stokes Building, 145 Studley Road, Heidelberg, 3084, Victoria, Australia

    Mahesha Weerakoon

  6. Memorial Sloan Kettering Cancer Center, New York, USA

    Behfar Ehdaie

  7. Epworth HealthCare, Melbourne, Australia

    Michael Fahey

  8. Emory University School of Medicine, Atlanta, USA

    Christopher Filson

  9. Monash University, Melbourne, Australia

    Mark Frydenberg

  10. Cambridge University Hospitals NHS Trust, Cambridge, UK

    Vincent Gnanapragasam

  11. Kagawa University Faculty of Medicine, Kagawa, Japan

    Yoshiyuki Kakehi

  12. Cleveland Clinic, Cleveland, USA

    Mike Kattan

  13. University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada

    Laurence Klotz

  14. University of Manchester, Manchester, UK

    Artitaya Lophatananon

  15. Sydney Prostate Cancer Center, Sydney, Australia

    David Malouf

  16. University College London & University College London Hospitals Trust, London, UK.,

    Caroline Moore

  17. University of Manchester, Manchester, UK.,

    Kenneth Muir

  18. Institute of Cancer research, The Royal Marsden, London, UK.,

    Chris Parker

  19. University of British Columbia, British Colombia Cancer Agency, Vancouver, Canada.,

    Tom Pickles

  20. Emory University School of Medicine, Atlanta, USA.,

    Martin Sanda

  21. Erasmus MC, Rotterdam, Netherlands.,

    Ewout Steyerberg

  22. Johns Hopkins University, Baltimore, USA.,

    Bruce Trock

  23. Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.,

    Riccardo Valdagni

  24. Princess Margaret Cancer Centre, Toronto, Canada.,

    Theo van der Kwast

  25. Centre Hospitallier Regional Universitaire de Lille, Lille, France.,

    Arnauld Villers

  26. Emory University School of Medicine, Atlanta, USA.,

    Theresa Wicklin Gillespie

  27. Sunnybrook Health Sciences Centre, Toronto, Canada.,

    Liying Zhang

Authors
  1. Sophie M. Bruinsma
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  9. Monique J. Roobol
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Consortia

the Movember GAP3 consortium

  • Behfar Ehdaie
  • , Michael Fahey
  • , Christopher Filson
  • , Mark Frydenberg
  • , Vincent Gnanapragasam
  • , Yoshiyuki Kakehi
  • , Mike Kattan
  • , Laurence Klotz
  • , Artitaya Lophatananon
  • , David Malouf
  • , Caroline Moore
  • , Kenneth Muir
  • , Chris Parker
  • , Tom Pickles
  • , Martin Sanda
  • , Ewout Steyerberg
  • , Bruce Trock
  • , Riccardo Valdagni
  • , Theo van der Kwast
  • , Arnauld Villers
  • , Theresa Wicklin Gillespie
  •  & Liying Zhang

Contributions

S.M.B., M.S.L., N.P., M.W. and L.P.B. researched data for the article. All authors provided a substantial contribution to discussions of content. S.M.B., M.S.L., N.P., M.W. and L.P.B. wrote the manuscript and all authors, and other members of the Movember GAP3 consortium reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Monique J. Roobol.

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Competing interests

The authors declare no competing financial interests.

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Bruinsma, S., Bangma, C., Carroll, P. et al. Active surveillance for prostate cancer: a narrative review of clinical guidelines. Nat Rev Urol 13, 151–167 (2016). https://doi.org/10.1038/nrurol.2015.313

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