Active Surveillance for Intermediate Risk Prostate Cancer

BACKGROUND: Utilization of active surveillance (AS) for prostate cancer is increasing. Optimal selection criteria for this approach are undefined and questions remain on how best to expand inclusion beyond typical men with very low or low risk disease. We sought to review the current experience with AS for men with intermediate risk features. METHODS: Pubmed was queried for all relevant original publications describing outcomes for men with prostate cancer managed with AS. Outcomes for patients with intermediate risk features as defined by the primary investigators were studied when available and compared with similar risk men undergoing immediate treatment. RESULTS: Cancer specific survival for men managed initially with AS is similar to results published with immediate radical intervention. A total of 5 published AS series describe some outcomes for men with intermediate risk features. Definitions of intermediate risk vary between studies. Men with Gleason 7 disease experience higher rates of clinical progression and are more likely to undergo treatment over time. Intermediate risk men with Gleason 6 disease have similar outcomes to low risk men. Men with Gleason 7 disease appear at higher risk for metastatic disease. Novel technologies including imaging and biomarkers may assist with patient selection and disease surveillance. CONCLUSIONS: The contemporary experiences of AS for men with intermediate risk features suggest that although these men are at higher risk for eventual prostate directed treatment, some are not significantly compromising chances for longer-term cure. Men with more than minimal Gleason pattern 4, however, must be carefully selected and surveyed for early signs of progression and may be at increased risk of metastases. Incorporating information from advanced imaging and biomarker technology will likely individualize future treatment decisions while improving overall surveillance strategies.